A Case Study in Turkey-Importance of Right
Nurse Staffing Plans and Ratios in Turkish Private Hospitals (Acibadem Healthcare Group)
Saliha Koc1*, Aslıhan
Bardak2
1Director, Acibadem Healthcare Group Nursing Services, Turkey
2Directorship
Project Specialist, Acibadem Healthcare Group Nursing
Services, Turkey
*Corresponding Author Email:
ABSTRACT:
Shortage of nurses in Turkey has gained momentum in recent years
and severely threatens
nursing profession. However, medical errors caused by lack of nurse staffing,
patient outcomes, increased infection rate, nurse burnout, nursing injuries
negatively affect the nurse-patient and hospital management at the same rate.
Today, arrangements on nurse staffing plan are still made according to the
prediction of the director nurse. Over the past 10 years, floors reshaped
according to nursing needs of patients and the number of
nurses included in staffing plan display a more realistic picture. Other than the number of nurses assigned to
floors, the factor of nurse workload planning is also an issue avoided to be
expressed in Turkey. The number of patients per nurse is twice the figure
recommended and no arrangement has been made on this matter, leading to
inefficient use of the nursing workforce. Our staffing plan based on patient
care needs (Acuity) which we introduced into Acibadem
Healthcare Group in 2005 offers a realistic approach to hospital managers by considering the
number of required and available nursing staff members and seasonal changes.
Study method is based on literature support, and our staffing plans we put into
use since 2009 when they are described.
KEY WORDS: Nurse staffing plan, nurse-to-patient ratio, nurse workload, AHG
case study.
1. INTRODUCTION:
Incomplete workforce planning
threatens patient health and decreases quality of nursing care. Also, problems
about workforce and staff planning underlie resignations caused by lack of
employees. In many scientific studies on nursing, it is stated that quality of
patient care could be increased and nurse resignations could be reduced by
nurse staff planning and increasing the percentage of nurses with a bachelor’s
degree. In the literature, it is
recommended that methods by which nurse work load is planned should be selected
according to specifications of hospitals and among those conforming to
workforce management.
For
continuity of patient safety and the nursing workforce, nurse-patient ratio
should be controlled by the state. By a
legal regulation to be made by the Ministry of Health, it will be possible to
turn a new page in the history of patient safety in Turkey.
For this, first of all,
nursing requirement of patients in floors and wards of public and private
hospitals in Turkey has to be established. At this point, patient dependency
coefficient should be defined according to patient dependency level. Patient
dependency level is determined by classification of patients. The next step, which is determination of
number of nurses per bed for each floor and ward, will give an accurate value
provided that bed occupancy rate is assumed to be 100%.
In Turkey, Acıbadem
Healthcare Group integrated nurse-to-patient ratio method into its health
information systems and has used this system since 2005. The ratio, which can
be monitored through Cerebral, the nursing console, is addressed in two
different aspects. The first is the number of nurses required and the second is
the number of nurses in the system. The
system calculates the number of nurses required by a specific floor and on the
other hand, finds the number of available nurses on that floor and shows the
difference. Therefore, the limits of compulsory nurse-to-patient ratio to close
this gap should be established by considering minimum values of World Health
Organization and other implementing countries. For Acıbadem
Healthcare Group, the
only limitation in this practice is that the cost paid to nursing workforce by
the hospital will increase because one nurse will be allocated to 5 patients,
while formerly one nurse was allocated to 7 patients.
Passage to mandatory
nurse-to-patient ratio of Acibadem Healthcare Group
will not cause any change in the current operational system. The only issue
that needs improvement is defined as the deviation in the number of nurses (the
difference between the number of nurses required and the number of those
available). Currently, although patient
outputs and nursing clinical indicators(pressure sores, patient falls, rate of
developing thrombophlebitis, satisfaction with
nursing care) of Acibadem
Healthcare Group is above the target rate, determination of nurse-to-patient
ratio for each unit is important since it will approach the methodology of “0
error” along with the new practice.
In 1960-1970s, a method called
“Utilized Work Sampling” was used. This method was not susceptible to type of
patient, skill mix and nursing process.
From mid-1970s to 1990, an
acuity-based staffing methodology was followed. Terminological equivalent of
acuity is referred to as medical measure of severity of disease or patient care
coefficient. Dependency can be expressed as nursing dependency of a patient up
to a certain degree. By the 1990s, a concept called nursing ratio was
introduced and measurements for performance were created. Undoubtedly, the key
factor for its creation was the pressure from the administration to reduce
nursing costs. In the late 1990s, trade unions found working system in the
California model advantageous in terms of work safety (Rogers, Overfelt, Mc Nally, 2003).
Nurse-to-patient ratio, a
staffing methodology, became a compulsory procedure for the first time in the
state of California, USA in 2004 (Coffman, Seago and Spetz, 2002; Spetz 2004). As of
September 2009, American Nurses Association (ANA), Columbia in conjunction with
14 states turned nurse staffing policies into procedures, while nurse staffing
legislation was created in 17 states.
According to a study conducted
by Rosseter (2011) with American Association of
Colleges of Nursing (AACN), the cost of a licensed nurse as a human resource to
the hospital was $2,820
(2011), while turnover cost of that nurse was considered as
$65,000 ($65,000). It emerged that annual percentage increase of nurse turnover
corresponded to $300,000(Hunt, 2009).
In a study by Johnson et al.
(2000), recruiting, training and orientation of someone else instead of a
former employee, corresponded to 50% of annual salary of the former employee.
Moreover, it is emphasized that the process of understanding the job and recognition
of the organization as well as its financial aspect have an effect on the
efficiency in the job. In addition, loss
of intellectual capital was also considered, and hidden loss of the
organization is that competing firms benefit from these values.
Nurse staffing plan increases
a nurse’s commitment to the institution while reducing stress. Because she pays
much more attention to the patient, this leads to correct application of the
treatment, and reduction in medication errors as well as hospital’s expenses on
recruitment and training (Aiken, 2008; Greenberg, 2006). From a social point of view, this leads to an
increase in nursing efficiency as well as wages and thus allows balancing the
extra costs. In addition, a better nursing care results in a decrease in future
drug spending and indirect care expenditures, including travel, loss of
productivity during doctor's appointment or in the time spent by patients'
relatives helping the patient. Therefore, determining the causes of turnover
and taking precautions are essential.
In an investigation with the
topic "nurse staffing, patient mortality, burnout and dissatisfaction”
conducted by Aiken et al.(1993), the maximum number of patients a nurse may
provide care for was established as 4. It was underlined that patient mortality
rate increased by 14% within 30 days if the number of patients provided with
care was 6, and by 31% if the number was 8.
The low number of nursing staff risks the quality of patient care. In
the case of research conducted in intensive care units, it was established that
22% of actual infections were related to health care. During a 24-hour
nurse-patient ratio of 1.9 on average, central venous catheter, mechanical
ventilation, urinary catheter-related infection rate and the use of antibiotics
were checked. A high nurse-patient ratio is positively related to a decrease of
30% in the risk of infection. Where nurse-patient ratio is more than 2.2, 26.7%
of all the infections can be avoided.
Current studies show that the
relationship between higher nursing staff and mortality is becoming more and
more complicated every day. Ten years ago, there was no sufficient evidence to
relate nurse staffing and patient output, whereas in 2002, Needleman et al.
established the relationship between nurse staffing levels and not being able
to keep a patient alive who experienced one of five complications, including
pneumonia, sepsis, heart attack, advanced stomach / intestinal bleeding and
deep vein thrombosis. By conducting a more comprehensive study than Needleman
et al.’s study, Aiken et al. measured numerical magnitude of the impact of
nurse staffing on mortality. In UK Rafferty(2007)
report, it is apparent that hospitals having a mortality ratio of 26% have a
very high patient to nurse ratio(low staff level).
Every year, a budget of $8.5 millon is prepared for nursing care indicators in pressure
sores and other categories.
The relationship between nurse
staffing level and patient output has been studied for over 10 years.
Considering the results of the studies conducted, it was observed that a
correct staffing plan led to a decrease in outputs such as mortality, not being
able to be saved, complications, infection rates, development of pressure
ulcers, falls, period of hospitalization and
medication errors (Mcgahan, Kochaski,
Coyer, 2012).
While emphasizing the
necessity of safe staffing level for quality patient care, RCN (2009) specifies
the evidence-based effects of high level of staffing found by research studies
as follows:
Increase in the quality of patient care
(positive patient output)
Increased nurse retention and recruitment
Providing economic
benefits to employer and society
20 years ago, insufficiency of
the number of nurses for a high-quality patient care was reported by Aiken and Mullinix (1987). Immediately afterwards, the Institute of
Medicine began working for the level of sufficient staff in clinics and
hospitals in 1993. Findings at the beginning of the study did not support the
relationship between nursing staff ratio and patient care (Wunderlich,
Sloan and Davis 1996). In 2002, the relationship between nurse staffing level
and patient output could be based on several pieces of evidence. Aiken et al.(2002) suggested that in case of any increase in the
workload, mortality rate in surgical interventions increased by 7%, leading to
subsequent increase in burnout and job dissatisfaction and unavoidable
resignations. Similar studies were also carried out in Canada, UK, Belgium, and
eventually 90 meta-analysis studies were assessed by the Agency for Health Care
Research and Quality and the relationship between patient output and nurse staffing was
formally approved (Kane et al., 2007).
It was noted that upon association
by government authorities of patient output with nurse staffing, staffing level of licensed nurses also
increased and staffing level of nurses with associate's degree decreased.
Although the costs of nurses with a bachelor’s degree are higher than nurses
with associate's degree, it is understood that it is the main labor force which
enhances the quality of patient care. Therefore, several improvements will be
observed in patient safety if an extensive space is allocated thereto in
staffing plan.
According to Rogers, Overfelt and Mc Nally(2003), there are 3 factors that are taken into consideration in staffing. These can be
listed as "hospital structure", "patient profile", "nursing unit". Because "age", "companion
care", and "training requirements" vary from patient to patient,
while the areas in which the hospital provides care also vary. In addition, the
design of nursing unit, unit equipment, helpandsupport
and IT units also affect nurse staffing.
Recent studies showed
that architectural structure of the hospital also has a major impact on the
workload of nurses. Studies demonstrating impact of architectural structure on
both patient health and performance of nursing were conducted by McCusker et al. (2004), Pattison and Robertson (1996).
Analyzing architectural structure of modern hospitals, it can be said that the
present situation is less costly than the past. The reason for this is that
since services are designed according to purpose, treatment takes one fifth
less time. Short hospitalization period is important for effectiveness of both
the patient and the hospital.
Hospitals are designed
according to 4 major structures, which include:
1. Bay Units
2. Nightingale Units
3. Hub and spoke Units
4. Other designs
In bay units, patients
of different genders and different classes may be included in the same unit.
Patient care cost does not vary according to patient dependency. Moreover, if
the necessary equipment is positioned in a place close to patient rooms, the
distance traveled by a nurse also decreases (Stichler,
2001). However, Bay design experiences problems at floors with staff shortage.
A centralized nurse station can tolerate the floors with staff shortage.
Although sub-stations in wide units with a regular nurse staff better organize
nurse-patient communication, nurses’ job satisfaction declines because they
feel isolated.
In bay type designs,
audible warning device system allows access of patient to the nurse. In case
this audible device sounds for too long, both patients and nurses are affected
negatively and their efficiency decreases. On the other hand, Bay design
configures a better staff and offers a number of modern facilities so it
creates an appropriate environment for the patients during their
hospitalization period. An example of modern facilities offered by Bays design
is patient-to-wc ratio. In Bays system, there are 6 patients per
toilet, whereas in Nightingale system, there are 12 patients per toilet
(Pattison and Robertson, 1996).
In Nightingale type of
design, patient rooms should be as large as possible and positioned in such a
way as to maximize visibility of nurse station and audibility of calls. In
Nightingale type of design, there is stronger communication between patients and
nurses (because of the position of nurse station). However, the most
significant handicap in this system is “noise” since the service covers more
number of patients. Pattison and
Robertson (1996), Stichler (2001), Topf (1985) reported that recovery rate of patients
suffering from noise-induced stress decreased. It was stated that in
Nightingale type wards, patients may be transferred between wards for 5 times,
and this situation is stressful for the patient and an extra workload for the
nurse (CABE, 2004; Lawson et al., 2003; Seelye,
1982).
Also in the case of
hub-and-spoke type designs, there is a nurse station positioned in the middle
of wards. According to nurses, the most ideal ward is where it is positioned in
such a way that it gets light and fresh air, and has a large storage area and a
regular fire exit. Based on the impressions of nurses, this is a unit where
patients requiring critical care should stay because the least waste of time on
the go takes place in this unit. It is a type of design in which the link
between the patient and nurse is healthy and management of which can be
provided better. In hub and spoke type
wards, a clear field of vision is available between the nurse and the patient
dependent on her. Similar to Nightingale
design, patient confidentiality will be reduced depending on the size of the
ward so there’ll be discomfort because there’ll be noise and patients will
witness other patients’ stress during their examination.
Other unit designs are
listed as "Racetrack", "Triangular", "Pyramid"
and no further detail was provided in the literature.
Although AHG has no
scientific data in this regard, there is no finding which associates
architectural structure of the hospital with the number of nurses. In a study
conducted by Hendrich et al. (2008), three different
areas (racetrack, corridor and radial) were evaluated by time and whether
architectural design affected a nurse’s time while she was carrying out care
activities. As a result of the study, it was concluded that there was no
statistically significant data. In the
same study, they indicated that during night shifts, nurses traveled less
distance because patients were less mobile and there was increased rate of
pain.
In AHRQ's nurse staffing, one
of two principles are taken as the basis.
These are:
Time spent by a nurse for one patient per
day
Nurse-to-patient ratio (the ratio of
licensed nurses’ RN+LPN/number of patients)
When we think of the time
spent by a nurse for one patient in a day, it ignores non- care-related
activities, even though it is considered as the most accurate measure. In
addition, time of care between nurses working in temporary periods on a monthly
basis and nurses working on a regular basis can be misleading.
Patient-nurse ratio, created
as a solution to such problems, also has advantages as well as disadvantages.
For example, measuring nursing care per minute is not economical and this ratio provides a more
realistic approach in the case of unit management and calculation of training
days. Today, nurse-to-patient ratio is used in many institutions throughout the
USA (Minnick and Mion, 2009).
Minimum nurse-to-patient ratio
according to health legislation published in California is shown in table 1 by
units and departments.
|
Type of
Unit |
Suggested
Nurse-Patient Ratio |
|
General
Medical Care |
1:5 or 1:6 |
|
General
Surgery |
1:5 or 1:6 |
|
Telemetry |
1:5 |
|
Pediatric |
1:4 |
|
Newborn |
1:8 |
|
Neonatal
Intensive Care |
1:2 or 1:3 |
|
Adult
Intensive Care |
1:2 or 1:3 |
|
Oncology |
1:4 or 1:3 |
|
Delivery
room |
Varies |
|
Antepartum; Section for postpartum high-risk patients |
1:5 or 1:6 |
|
Postpartum |
1:6 |
|
Psychiatry |
1:7 |
|
Departments |
Nurse-Patient Ratio |
|
Medical and surgical |
1:5 |
|
Pediatric |
1:4 |
|
Intensive-care |
1:2 |
|
Oncology |
1:5 |
|
Obstetrics and gynecology |
1:3 |
Findings of large-scale study
conducted by RCN on 9000 nurses in 2009 are given below.
|
|
Day |
Night |
|
Number of
beds |
24 |
24 |
|
Total
number of patients |
23 |
22 |
|
Occupancy |
%97 |
%92 |
|
Number of
nurses with a bachelor’s degree |
3.3 |
2.5 |
|
Number of
healthcare support staff members |
2.2 |
1.5 |
|
Number of
staff members on duty (nurses with a bachelor’s degree – healthcare support
staff members) |
5.4 |
3.9 |
|
Ratio of
nurses with a bachelor’s degree to other nursing staff members |
%60 |
%62 |
|
Average
number of nurses with a bachelor’s degree |
7.9 |
10.6 |
|
Number of
patients per nursing staff member |
4.4 |
6.1 |
|
Number of
cases |
713 |
324 |
According to Hayes (1991),
necessary and appropriate health care will be provided if patient dependency
and level of staffing match one-to-one. Many calculation methods only meet
physical needs of the patient.
In a study conducted in
Nuffield Health Institute in 2003, Hurst stated that nurse staffing plan can be
made in 5 different ways. These are:
1. Professional
Judgment Approach
2. Nurses per
occupied bed method
3. Timed-task/activity
approaches
4. Regression-based
systems
5. Acuity-quality
method
This approach provides the
most appropriate size for the unit, and optimum creation of the nursing
team. In principle, it changes duty
route into labour format.
|
Shift
Information |
Duration
of Daily Work |
Total Time
of Work |
|
Morning
shift: X hrs
from....to.... |
X*number
of nurses*7 |
XZ hrs |
|
Night
shift: Y hrs
from... to.... |
Y*number
of nurses*7 |
YZ hrs |
|
Total |
= |
XYZ hrs |
In a unit where weekly work
load is established as XYZ hrs, nurse’s leaves should also be taken into
account. Nuffield Institute For Health (2003) defines
this time as a “time-out” and represents it as 22%. Therefore, total time of
work should be multiplied by time-out in the new calculation. The
abovementioned method is not only easy to calculate but also low in costs and
operable in every area of the clinic.
Certain care groups may require minor adjustments. However, it is
difficult to explain the relationship between staffing and nurse quality by
this method. On the other hand, there’ll be a trouble in the calculation when
number of patients and patient dependency level are changed so the ward will be
over- or understaffed.
In this method, staffing and
nursing skills mix show an empirical variety. Data such as formula, bed
occupancy and payroll information are collected in a routine fashion.
It establishes very little
relationship between ward data, ward size and occupancy. Moreover, the formula
is insensitive to dependency level changes and the same number of nurses can
remain inadequate in high dependency patients. Lastly, routinely collected
data, data such as bed occupancy used in staffing formula are error-prone and
they are confirmed after their accuracy and reliability are established.
This is a method to which
nurses refer while making care plans.
What is essential here is to arrange the amount of time spent for a
patient during an intervention according to need. Each patient’s daily care needs are
determined manually or electronically by checking via a checklist of nursing
interventions.
Regression analysis or in
other words demand analysis determines the number of nurses necessary for a
specific activity. Outcome of regression analysis is mostly as follows: The
number of nurses increases as bed occupancy increases
and accordingly estimated number of staff members also increases. Regression
analysis is appropriate where it is possible to make predictions, e.g. in the
case of planned patient admissions. Nursing staff members in the unit are
shaped in line with bed occupancy and patient demand.
Third method used to estimate
and evaluate the size and mix of nursing team in wards is referred to as “dependency-activity-
quality” method. This staffing method improves weak points of the methods
mentioned above. It is especially useful for wards where patient numbers and
patient mixes fluctuate. Formula is not only sensitive to the number and mix of
patients but also evaluated patient floor. Therefore, the formula used is more
complex to derive and use.
Patients with a dependency
level of 1 are independent of nurses and those with a dependency level
of 4 are completely dependent on nurses.
1. In stage 1, duration of care by dependency should be indicated
in minutes.
2. In stage 2, nurse to patient ratio should be calculated.
At this stage, we have to
calculate care time difference in hrs between patients with dependency level 1
and patients with dependency level 4, by taking the table above as the basis.
3. Stage 3, calculating workload throughout the hospital (Acuity)
Formula : Workload/number of patients
4. Stage 4, Calculating Bed Acuity (Future Projection)
Even though workload and bed
acuity are sufficient in the scope of criterion, bed acuity as well as bed
occupancy should be known. If formulated, total workload/bed occupancy=bed
acuity
5. Stage 5, how much time is necessary for good care?
Direct care time for all
patients is: workload x dependency level/60 minutes
6. Stage 6, Calculating the time spent by
a nurse while providing direct care
7. Stage 7, Deducting Meal Breaks from Care Time
Nurses spend a certain part of
their time when they provide care, for meal breaks. While calculating care
times, this detail should be taken into consideration.
8. Stage 8, Taking Sick Leave, Annual Leaves into Consideration
Such periods are also called
time-out. While calculating number of staff members, this factor should also be
taken into account.
9. Stage 9, Converting Nurse Care Hours into Weekly Work Format
10. Assigning Time Schedule According to Nursing Skills
As Acıbadem
Health Group (AHG), we’re using ACUITY method during nurse staff
planning.
Because, other than available
values, it calculates values such as bed acuity. Unit occupancy and patients
dependency can be adjusted in a mixed way. Values in other timed-task-activity
and regression models do not take patient care coefficient as the basis, however, they are also not sensitive to change.
Acıbadem Health Group works on “acuity” method,
which assigns adequate quantity of workload for patient care. Additionally, the
fact that it is the only model with applicability and confidence in terms of
literature(that it has more advantages than the other 4 models) and that Mayo
Clinic, Cleveland, Mass General Hospital also incorporated this method into
their own methodologies was a decisive factor. Acuity method was activated
randomly-manually in AHG between 2003-2008, and transferred into the system in
2008 and its use in all hospitals was initiated in 2009 .
It has a total of 23
hospitals, including 14 hospitals and nine polyclinics. A total of 2372 nurses
are on duty in these 23 hospitals. In AHG, nurse staffing is conducted by a
health management program we call Cerebral.
Findings
Given AHG’s location and
service data, no correlation could be established between “Female” and “Male”
patients and their level of dependency. Since the services they benefit from
mainly arise from gender difference(e.g. the fact that
number of female patients is higher in obstetrics and gynecology, aesthetic,
plastic and reconstructive surgery, that number of male patients is higher in
ear-nose-throat and urology departments), it could be misleading to make some
kind of comparison between patient care coefficient and the level of
dependency.
Patient
Age Group
AHG’s patient age group range
is “0-65” and is classified under 4 categories: “newborn”, “child”, “adult” and
“elderly”. In order to make the data more understandable, AHG patient age
groups are categorized as follows:
|
Age |
Group |
|
0-1 year |
Newborn |
|
2-14 years |
Child |
|
15-65 years |
Adult |
|
65<= |
Elderly |
In the light of the data of Acibadem
Maslak Hospital for the year 2012, patient care time
in hrs and patient care coefficient vary by age group.
|
Age group |
Patient Care Time in Hrs |
Patient Care |
|
0-6 |
11,77 |
0,44 |
|
7-14 |
10,62 |
0,44 |
|
15-65 |
10,70 |
0,46 |
|
65<= |
11,23 |
0,45 |
As can be seen in the practice
above, one of the most important factors that affect the number of nurses is
the number of patients so there is no correlation which can be largely
substantiated between the number of nurses and the patient age group.
It is calculated on the basis
of dependency level according to Rush Medicus scale
and studied in 4 individual groups.
|
Type of dependency |
Care time in Hrs |
|
Independent Patient |
0-2 hrs |
|
Low level dependent patient |
2-4 hrs |
|
Mid-level dependent patient Lower level dependent patient |
4-10 hrs |
|
High level dependent patient Mid-level dependent patientLower level dependent patient |
10-14 hrs |
In addition to Rush Medicus patient classification scale, AHG works on a
classification by The Association of UK University Hospitals (AUKUH) as a pilot
practice for improving the quality of patient care.
|
Care level |
Criteria |
|
Level 0 Level 0 |
Independent patient; the group in which patients requiring post
diagnostic care and ongoing medication treatment or awaiting discharge are
included. |
|
Level 1 Level 1a |
Level 1 inpatient; the group which includes patients whose
post-op care requires more than basic needs. |
|
Level 1b |
The patient group in which patients are
in a stable condition but have an increased dependence on nurse. |
|
Level 2 |
The patient group in which patients are in an unstable condition
and at risk and should not be included in inpatient floor. |
|
Level 3 |
The group in which patients needing intense respiratory support
and having multiple organ deficiency are included. |
|
Subject |
AHG |
AUKUH |
|
Dependency
levels and Patient Classification |
Studied in
4 groups. |
Studied in
5 groups. |
|
Using
Patient Dependency Coefficient |
Calculated
individually for every patient. |
5
different coefficients designated according to patient dependency levels are
used |
|
Connection
with Quality Indicators |
Emphasizes
time spent by a nurse while she is next to a patient |
Studied as
integrated into nurse workload planning as official complaints, drug errors,
MRSA, C-diff, falls, pressure ulcers and nutrition under the heading “Nursing
Sensitive Indicators”. |
|
Determination
of nursing requirement |
Annual
calculations are made. |
Monthly
(25 days) |
Unlike AHG, it studies the
patients in Level 1 in 3 perspectives.
AHG wards are gathered
under the following 7 departments according to the unit standr
used in California, New Jersey and Pennsylvania hospitals.
Patient dependency
coefficients calculated according to these departments are given in the table
below.
Table 10: 2012 AHG
Patient Dependency Coefficients by Universal Departments
|
Departments
|
Patient
dependency coefficient |
|
1General
Medical Care |
0,74 |
|
2Surgical
Care |
0,76 |
|
3Pediatrics
Unit |
0,80 |
|
4 Obstetrics
and Gynecology |
0,72 |
|
5Oncology
Unit |
0,81 |
|
6Intensive
Care Unit |
0,96 |
1Skin Diseases, Endocrinology, Gastroenterology, Chest
Diseases, Ophthalmology, Internal Medicine, Cardiology, Ear Nose and Throat,
Nephrology, Neurology, Orthopedics and Traumatology,
Urology, Infectious Diseases, Hematology, Endoscopy, and Psychiatry.
2Brain and Neurological Surgery, Pediatric Surgery,
Aesthetic, Plastic and Reconstructive Surgery, General Surgery, Thoracic
Surgery, Cardiovascular Surgery, Hand Surgery.
3Children's Diseases, Pediatric Allergy, Pediatric
Gastroenterology, Pediatric Hematology, Pediatric Cardiology, Pediatric
Infectious Diseases, Pediatric Pulmonology, Pediatric
Oncology, Pediatric Nephrology, Pediatric Neurology, Pediatric Neurosurgery.
4Obstetrics and Gynecology, Gynecologic Oncology, Perinatology, IVF and Reproductive Health Center.
5Medical Oncology, Radiation Oncology.
6Intensive Care, Intensive Coronary Care, Intensive
Cardiovascular Care
Calculation of number
of nurses is based on patient care coefficient. This coefficient is considered
while deciding on the number of nurses required by a unit.
6. DISCUSSION:
It is apparent that
“California” and “Victoria” are the models mentioned the most in available
nurse staffing system literature, and are used widely. Units taken as the basis
by both models may vary (see Annex-7.). Thus, comparison of nurse-to-patient
ratio related to 6 basic unit titles is given in Table 17.
|
|
California* |
Victoria** |
AHG*** |
|
General
Medicine |
1:5 |
1:4 |
1:4-1:5 |
|
Surgery |
1:5 |
1:3 |
1:3-1:5 |
|
Pediatrics |
1:4 |
1:4 |
1:3-1:4 |
|
Gynecology
and Obstetrics |
1:3 |
1:4 |
1:5 |
|
Oncology |
1:5 |
1:3-1:4 |
1:3-1:5 |
|
Intensive
Care |
1:2 |
1:2 |
1:2 |
* California, year 2008, nurse-to-patient ratio arrangement
* Victoria, year 2001, nurse-to-patient ratio arrangement
***AHG year 2012, nurse-to-patient ratio findings
For AHG, it can be
said that average number of patients a nurse provided care in one shift varied
between 4 and 5 in the year 2012. This
table confirms the table above.
There are 40 nursing
job descriptions in quality documentation system set out by staff planning in
AHG. These job descriptions are considered under 4
different titles, which are "the main purpose", "main
responsibilities", "profile (education level, experience, knowledge,
skills)" "position in the organization".
Nursing positions
defined in the system are listed below:
• Emergency Room Nurse Job Description
• Job
Description of Operating Room Nurse
• Job
Description of Operating Room Nurse in Charge
• Job
Description of Angiography Service/Laboratory Nurse
• Job
Description of Diabetes Education Nurse
• Job
Description of Maternity Nurse
• Job
Description of Training and Development Nurse
• Job
Description of Additional Duty - EEG / EMG Nurse / Technician
• Job
Description of Additional Duty - Workplace Nurse
• Job
Description of Additional Duty - Stoma Therapy Nurse
• Job
Description of Additional Duty - Triage Nurse
• Job Description
of Endoscopy Nurse
• Job
Description of Infection Control Nurse
• Job
Description of Hemodialysis Nurse
• Job
Description of Director of Nursing Services
• Job
Description of Nursing Services Development Manager
• Job
Description of Deputy Director of Nursing Services / Nurse in Charge of Patient
Care
• Job
Description of Director of Nursing Services
• Job
Description of Intravenous Therapy and Transfusion Team (IV Team) and
Blood-taking Nurse
• Job
Description of Outpatient Maternity Nurse
• Job
Description of Bone Marrow Transplant Nurse
• Job
Description of Clinical Education Nurse
• Job
Description of Central Sterilization Nurse
• Job
Description of Central Sterilization Nurse in Charge
• Job
Description of Oncology Nurse
• Job
Description of Special Branch - Oncology Nurse Case Manager
• Job
Description of Special Branch - Newborn Home Visiting Nurse
• Job
Description of Special Branch - Sexual Dysfunction Nurse
• Job
Description of Special Branch - Special Clinical Case Manager Nurse
• Job
Description of Special Branch-High Risk Pregnancy Nurse
• Job
Description of Outpatient Clinic Nurse
• Job
Description of Radiation Oncology Nurse
• Job
Description of Ward Nurse
• Job
Description of Nurse in Charge
• Job
Description of Trainee Nurse
• Job
Description of Medical Imaging and Interventional Radiology (TGGR) Department
Nurse
• Job
Description of Sleep Laboratory and Video-EEG Monitoring Nurse
• Job
Description of Reproductive Health Nurse
• Job
Description of Newborn Nurse
• Job
Description of Intensive Care Nurse
AHG Nursing
Performance Process
In AHG, there is an evaluation
process according to each job description.
1. AHG Competency Based Performance Evaluation: It is conducted once a year and evaluation
is based on competency levels.
2. Training Needs Analysis Exam: It is held once a year and its purpose is to evaluate
training courses given during the year. Results of training exam are among the
criteria in making career planning.
3. Nurse Performance Ratings: It is assessed on a personal basis once a month and its
results are used in performance system, personal development.
4. Quality Indicators followed by Acibadem
Healthcare Group: Acibadem Healthcare Group has monitored nursing quality
indicators in order to measure and improve nursing care quality, patient safety
and satisfaction with nursing services since 2002. These indicators are universally recognized “NDNQI
“’indicators and those currently monitored are given below:
·
Daily
time spent per patient
·
The
percentage of inpatients who developed pressure ulcers
·
Rate
of inpatient falls
·
Patient’s
satisfaction with the nurse
·
Patient’s
satisfaction with pain management
·
Patient’s
satisfaction with nurse’s training
·
Nosocomial
infections
·
Nurse
satisfaction
·
Nurse
education levels
·
Nurse
vacancy rate
·
controllable
resignations
·
Non-controllable
resignations
·
Rate
of patients for whom nurse’s first assessment was documented on time
·
Rate
of satisfaction with our nurses
·
Incorrect
administration of medication
·
Rate
of patients who developed thrombophlebitis after IV cannulation
·
Rate
of inpatients who developed hypoglicemia
·
Rate
of inpatients who developed hyperglicemia
·
Rate
of development of port infection in oncology patients with inserted port needle
·
Rate
of development of extravasation in oncology patients
with IV cannulation and inserted port needle
·
Number
of patients who received diabetes training and returned to emergency room
·
Rate
of newborns who were only breastfed during their hospital stay
The indicators listed
above were revised during “Nursing Council” periodically issued by Directorate
of Nursing Services and "rate of inpatients who developed hypoglycemia and
hyperglycemia" was removed from the list and "Number of Multiple
Attempts at Vascular Access Placement", "Number of Specialist
Nurses", "Smoking Rate of Nurses", "Ratio of Extravasated Liquid", "Rate of Falls and
Development of Pressure Ulcers in Patients with high risk of Pressure Ulcers
and Fall" were added in the year 2013.
5. Nursing Services
Quality Indicators: AHG nursing performance is measured by
taking “nursing care indicators (nurse clinical indicators)” and “nurse vacancy
rate” into account.
Nursing care
indicators are listed below:
• Rate of Inpatients who developed pressure
ulcers
• Rate of Inpatient Falls
• Rate of patients for whom nursing first
assessment was documented on time
• Rate of
patients who developed thrombophlebitis after IV cannulation
• Eate of Patient’s
satisfaction with pain management
• Rate of Patient’s satisfaction with the nurse
• Rate of satisfaction with our nurses
Since 2007, the
above-mentioned indicators are accessible to the public under the title of
"nursing quality indicators" at "Acibadem
Hemşirelik (Acibadem
Nursing)" homepage.
Healthcare Commission states
that staffing should be revised at least once every 2-3 years. However, RCN
mentions that early revision may be required in the following circumstances:
·
Where
patient complaints and adverse events take place
·
Where
healthcare-associated infections increase
·
In
case of any failure to exercise policies and procedures and any decline in care
standards
·
In
case of an increase inn employee turnover
·
In
case employee morale is low
·
Where
it is not known how an employee will have access to any training she has to get
·
Where
there is not enough time for practice and developing novelties
·
When
any change is introduced into care model
·
In
case of any interruption in communication
·
When a
variance is observed in bed occupancy and patient dependency
·
In
case of any change in local and national standards.
7.
CONCLUSION:
A nurse staffing plan with a
proper level is essential for safe patient care. Main clinical indicators
considered as criteria in patient care quality fluctuate according to correct
staffing plan. Staffing plan is not only a matter that should be taken
seriously for patient safety but also for employee safety. Today’s nurses
resign from the organization for three reasons if AHG is considered. These are
"family reasons", "busy working hours" and
"salary". Busy working hours" and "salary", two of the
foregoing reasons, are also the most common reasons given in many companies.
Busy working hours are associated with several deficiencies in staffing plan.
Nurses who work intensively have a high rate of making errors- being injured-
causing injury and high burnout and their communication with the patient is at
minimum level. Other than sentinel increase in cases, negative patient output
and nurse satisfaction, another aspect of working hours is the cost. Effect of
staffing plan should be examined in three aspects, which are
patient-nurse-hospital. Currently, the number of patients
that a nurse should provide care for is not based on solid foundations, and is
addressed as a commercial matter in our country and many other countries.
Thus, 9-12 patients are assigned to each nurse and patient care quality and
employee safety is compromised. Backed by laws, various states in the
USA(Washington, Orlando, California, Nevada, Texas, Illionis,
New York, New California, Ohio ) which set out to provide a solution to this
issue converted minimum nurse staffing ratio into a procedure(The American
Nurses Association’s Nationwide State Legislative Agenda, January 2012). In Turkey, although there is no attempt to do
something about this, nursing profession suffers each day and is not preferred.
In this study, the objective was to set forth the most suitable staffing plan
by taking nurse and patient factors into account.
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Received on 20.08.2013 Modified on 12.09.2013
Accepted on 25.09.2013 ©
A&V Publication all right reserved
Asian J. Nur. Edu. & Research 4(2): April- June 2014; Page 245-254