- Email: [email protected]
Consistency does count! Rethinking our approach to nursing assignments
Geriatric Nursing 38 (2017) 251e252
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Acute Care of the Elderly Column
Elizabeth Capezuti, PhD, RN, FAAN
Sarah Hope Kagan, PhD, RN, FAAN
Mary Beth Happ, PhD, RN, FAAN
Lorraine C. Mion, PhD, RN, FAAN
Consistency does count! Rethinking our approach to nursing assignments Lorraine C. Mion, PhD, RN, FAAN *, Jacalyn Buck, PhD, RN, NEA-BC
External pressures, both within and outside the hospital setting, define so much of what we do as hospital nurses. The way we determine unit nurse-patient assignments is one area still under our purview and control. Matching the patient to the appropriate and available nursing personnel impacts not only patient safety but also quality of care. This is especially true when we consider the needs and outcomes of hospitalized older adults. Fifteen percent of older adults are hospitalized annually and account for 40% of all hospitalized adults.1 Older hospitalized adults are an especially vulnerable group of patients with higher rates of hospital adverse events and complications as compared to other adults. Because of their diminished physiologic, physical and cognitive reserves, older adults are not as capable of recovering from acute illnesses but also not as capable of withstanding the pressures of hospital procedures and processes. Inouye and Charpentier2 in their groundbreaking work on delirium in older hospitalized adults presented an elegant framework that demonstrated the interaction of intrinsic risk factors with precipitating (hospital process) risk factors (e.g., frequent night awakening for vital signs and treatments, prolonged bed rest). As the person’s intrinsic risk factors increases, it takes fewer precipitating factors to incur delirium. The term ‘hazards of hospitalization’ was coined over 50 years ago and continues to be an issue today.3,4 For older adults, common complications of hospitalization are physical functional decline, delirium or worsening cognitive impairment, and falls. Nurses are the healthcare professionals who can mitigate the onset of these complications through careful ongoing assessments and
* Corresponding author. E-mail address: [email protected] (L.C. Mion). 0197-4572/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2017.05.006
monitoring, implementation of protocols to enhance function and cognition, and coordination of care. Why consistent nursing assignments? Consistent nurse-patient assignments have long been considered the gold standard of nursing care delivery in a variety of healthcare settings. Consistent assignments allows the nurse to know the patient and thus enhance patient-centered care. As we gain familiarity with the patient and family members, we can more easily identify the person’s values, preferences and health outcomes. Consistent assignments also allows a nurse to identify the older adult’s physical, psychological, physiological and cognitive baseline status, which in turn enhances the ability to monitor and more quickly determine the effectiveness of treatments, identify deteriorating conditions earlier in their course, and enhance care coordination and discharge. Older adults often present with nonspecific or vague symptoms, such as lethargy or falls, in the presence of acute events, including acute myocardial infarction, pneumonia and sepsis.5 Thus, early detection is essential and consistent assignments provide nursing personnel with the familiarity and ability to identify deterioration in a timely manner. From the patient and family perspective, having consistent caregivers engenders a sense of trust as it limits the number of times the patient needs to answer the same history taking questions. Indeed, the nurseepatient relationship is a powerful one .. But not one we necessarily appreciate. When still a new clinical nurse specialist in a county hospital, LM observed that the same nurse often did not have the same patients on sequential days. It was striking how a patient perceived the change in assignment and thought she had offended the nurse.
252
L.C. Mion, J. Buck / Geriatric Nursing 38 (2017) 251e252
Challenges to consistent nursing assignments There are a number of challenges to instituting consistent nursepatient assignments. Charge nurses weigh multiple factors when determining assignments: the number and acuity levels of the patients, skills and knowledge necessary to oversee the patient’s care, and the number, competencies, and skill mix of the nursing personnel. Besides addressing patient-specific care needs, charge nurses also balance the work equity among the nursing staff.6 A second challenge is the [nearly] universal use of 12 h shifts combined with a nursing shortage. Traditionally, nurses were scheduled in three 8-h shifts, i.e., day, evening and night shifts. When managed care and serious nursing shortages occurred in the late 1980s and early 1990s, hospitals shifted from a 5-day a week 8h shift to a 3-day a week 12-h shift as a recruitment strategy as well as an efficient scheduling tactic.7 Nurses enjoy the greater time off and reduced commuting time with the fewer days of work. Other benefits include reduced hand offs and potential reduction in errors. Since the 1980s, patient acuity has worsened and the pace and workload of hospital nurses has increased. There is a growing body of evidence, both in research and anecdotally, that the 12-h shifts are associated with greater patient harm and dissatisfaction.8,9 With longer shifts, fatigue can lead to lapses in concentration and resultant error; not only are the patients harmed, but nurses can become the second victims of the error with resultant disciplinary or legal retributions.10 Other deleterious effects on nurses include burnout, physical harm, for example falling asleep when driving home, and negative consequences on home life.9 In response to the evidence that sequential days of 12-h shifts can be detrimental both to patients and nurses, many organizations have instituted the Institute of Medicine’s recommendation to limits nurses’ work hours to 12 h in a twenty-four hour period and no more than 60 h in a week.11 In practical terms, this means that nurses can work 2 sequential days of 12 h shifts with one or two days off before returning to work. Thus there is a high likelihood that patients will be cared for by a number of nurses during their hospital stay. Last, with a significant proportion of nurses older than 4012 and higher acuity caseload, the 12-h shift is not a ‘one size fits all’. Older nurses need longer recovery times from the physical, cognitive and psychological demands of their work,12,13 and are also at greater risk for acquiring work-related injuries.13 Strategies to enhance consistent nursing assignments Twelve-hour shifts are likely here to stay because they fit the lifestyle needs of so many nurses. We will continue to have a nursing workforce shortage. Finally, our hospital patient population will continue to age with concomitant higher vulnerability and need for enhanced vigilance. Our challenge then is to determine creative and flexible ways we can deliver cost-effective care to patients using the principles of consistent assignment while maintaining a conducive work environment for our nurses. A therapeutic older adult-hospital fit consists of four dimensions: the social climate, physical design, policies and procedures, and care systems and processes.14 In an integrative review of 66 hospital studies aimed at improving hospital care for older adults, few studies elaborated on care systems and processes and little is known on resource allocation and detailing of what was done to achieve patient, nurse or organizational outcomes.14 With the aging population and ongoing nursing shortage, we will need to identify ways to address consistent assignments and conducive nurse work
environments. Importantly, we need to share our programs and experiences with one another. Kimball and colleagues15 conducted an in depth search and review of 45 existing models of care and profiled five new models of care delivery. Common elements among these successful models were an elevated role played by the RN; greater focus on the patient and role of the patient and family; enhancing patient transitions and handoffs, especially for complex older adult patients; using technology to enhance point of service care, such as pharmacy robots or remote monitoring stations; and ongoing feedback of results. Several sites have devised and implemented successful RNled teams consisting of RNs, licensed practical nurses (LPNs), and unlicensed nursing assistants (UNA).16e18 The studies did not explicate whether team memberships were consistent or varied daily. Nor did they explicate unique roles for aging nurses or varying shift patterns, which may or may not enhance consistent assignments. Utilizing an elevated team approach with established team members would enhance consistent assignment principles by ensuring overlapping team members would know the patient and family. Last, hospitals and units need to examine context-specific aspects of nursing delivery models. This will ensure best approaches to meeting the needs of our older adult patients .. and of our nurses. References 1. Administration on Aging. A Profile of Older Americans 2016. Accessed 22 March 2017 https://aoa.acl.gov/Aging_Statistics/Profile/index.aspx. 2. Inouye SK, Charpentier PA. Precipitating factors for d elirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852e857. 3. Schimmel EM. The hazards of hospitalization. Ann Intern Med. 1964;60: 100e110. 4. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(30):219e223. 5. Boockvar KS, Lachs MS. Predictive value of nonspecific symptoms for acute illness in nursing home residents. J Am Geriatr Soc. 2003;51:1111e1115. 6. Allen SB. The nurse-patient assignment: purposes and decision factors. J Nurs Admin. 2015;45(12):628e635. 7. Sherman RO. The Dilemma with the 12-hour Nursing Shift. Accessed 22 March 2017 http://www.emergingleader.com/12-hournursingshift/. 8. Trinkoff M, Johantgen M, Storr CL, Gurses AP, Liang Y, Han K. Nurses’ work schedule characteristics, nurse staffing and patient mortality. Nurs Res. 2011;60(1):1e8. 9. Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff. 2012;31(11):2501e2509. 10. Agency for Healthcare Research and Quality. Nursing and Patient Safety. July 2016. Accessed 22 March 2017. https://psnet.ahrq.gov/primers/primer/22. 11. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington DC: National Academies Press; 2003. 12. American Nurses Association. Fast Facts. The Nursing Workforce 2014: Growth, Salaries, Education, Demographics and Trends. Accessed 22 March 2017. http:// nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/work force/Fast-Facts-2014-Nursing-Workforce.pdf. 13. Harrington L, Heidkamp M. The Aging Workforce: Challenges for the Health Care Industry Workforce. National Technical Assistance and Research Center to Promote Leadership for Increasing the Employment and Economic Independence of Adults with Disabilities. Accessed 22 March 2017. https:// www.dol.gov/odep/pdf/NTAR-AgingWorkforceHealthCare.pdf. 14. Parke B, Hunter KF, Bostrom AM, Chambers T, Manraj C. Identifying modifiable factors to improve quality for older adults in hospital: a scoping review. Int J Older People Nurs. 2014;9(1):8e24. 15. Kimball B, Cherner D, Joyn J, O’Neil SE. The quest for new innovative care delivery models. J Nurs Admin. 2007;37(9):392e398. 16. Hastings SE, Suter E, Bloom J, Sharma K. Introduction of a team-based care model in a general medical unit. BMC Health Serv Res. 2016;16:245e256. 17. Rudisill PT, Dienemann J, Callis C, Samuelson M, Hardin SR. Care Redesign. A higher-quality, lower-cost model for acute care. J Nurs Admin. 2014;44:388e394. 18. Cann T, Gardner A. Change for the better: an innovative model of care delivering positive patient and workforce outcomes. Collegian. 2012;19:107e113.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Acute Care of the Elderly Column
Elizabeth Capezuti, PhD, RN, FAAN
Sarah Hope Kagan, PhD, RN, FAAN
Mary Beth Happ, PhD, RN, FAAN
Lorraine C. Mion, PhD, RN, FAAN
Consistency does count! Rethinking our approach to nursing assignments Lorraine C. Mion, PhD, RN, FAAN *, Jacalyn Buck, PhD, RN, NEA-BC
External pressures, both within and outside the hospital setting, define so much of what we do as hospital nurses. The way we determine unit nurse-patient assignments is one area still under our purview and control. Matching the patient to the appropriate and available nursing personnel impacts not only patient safety but also quality of care. This is especially true when we consider the needs and outcomes of hospitalized older adults. Fifteen percent of older adults are hospitalized annually and account for 40% of all hospitalized adults.1 Older hospitalized adults are an especially vulnerable group of patients with higher rates of hospital adverse events and complications as compared to other adults. Because of their diminished physiologic, physical and cognitive reserves, older adults are not as capable of recovering from acute illnesses but also not as capable of withstanding the pressures of hospital procedures and processes. Inouye and Charpentier2 in their groundbreaking work on delirium in older hospitalized adults presented an elegant framework that demonstrated the interaction of intrinsic risk factors with precipitating (hospital process) risk factors (e.g., frequent night awakening for vital signs and treatments, prolonged bed rest). As the person’s intrinsic risk factors increases, it takes fewer precipitating factors to incur delirium. The term ‘hazards of hospitalization’ was coined over 50 years ago and continues to be an issue today.3,4 For older adults, common complications of hospitalization are physical functional decline, delirium or worsening cognitive impairment, and falls. Nurses are the healthcare professionals who can mitigate the onset of these complications through careful ongoing assessments and
* Corresponding author. E-mail address: [email protected] (L.C. Mion). 0197-4572/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2017.05.006
monitoring, implementation of protocols to enhance function and cognition, and coordination of care. Why consistent nursing assignments? Consistent nurse-patient assignments have long been considered the gold standard of nursing care delivery in a variety of healthcare settings. Consistent assignments allows the nurse to know the patient and thus enhance patient-centered care. As we gain familiarity with the patient and family members, we can more easily identify the person’s values, preferences and health outcomes. Consistent assignments also allows a nurse to identify the older adult’s physical, psychological, physiological and cognitive baseline status, which in turn enhances the ability to monitor and more quickly determine the effectiveness of treatments, identify deteriorating conditions earlier in their course, and enhance care coordination and discharge. Older adults often present with nonspecific or vague symptoms, such as lethargy or falls, in the presence of acute events, including acute myocardial infarction, pneumonia and sepsis.5 Thus, early detection is essential and consistent assignments provide nursing personnel with the familiarity and ability to identify deterioration in a timely manner. From the patient and family perspective, having consistent caregivers engenders a sense of trust as it limits the number of times the patient needs to answer the same history taking questions. Indeed, the nurseepatient relationship is a powerful one .. But not one we necessarily appreciate. When still a new clinical nurse specialist in a county hospital, LM observed that the same nurse often did not have the same patients on sequential days. It was striking how a patient perceived the change in assignment and thought she had offended the nurse.
252
L.C. Mion, J. Buck / Geriatric Nursing 38 (2017) 251e252
Challenges to consistent nursing assignments There are a number of challenges to instituting consistent nursepatient assignments. Charge nurses weigh multiple factors when determining assignments: the number and acuity levels of the patients, skills and knowledge necessary to oversee the patient’s care, and the number, competencies, and skill mix of the nursing personnel. Besides addressing patient-specific care needs, charge nurses also balance the work equity among the nursing staff.6 A second challenge is the [nearly] universal use of 12 h shifts combined with a nursing shortage. Traditionally, nurses were scheduled in three 8-h shifts, i.e., day, evening and night shifts. When managed care and serious nursing shortages occurred in the late 1980s and early 1990s, hospitals shifted from a 5-day a week 8h shift to a 3-day a week 12-h shift as a recruitment strategy as well as an efficient scheduling tactic.7 Nurses enjoy the greater time off and reduced commuting time with the fewer days of work. Other benefits include reduced hand offs and potential reduction in errors. Since the 1980s, patient acuity has worsened and the pace and workload of hospital nurses has increased. There is a growing body of evidence, both in research and anecdotally, that the 12-h shifts are associated with greater patient harm and dissatisfaction.8,9 With longer shifts, fatigue can lead to lapses in concentration and resultant error; not only are the patients harmed, but nurses can become the second victims of the error with resultant disciplinary or legal retributions.10 Other deleterious effects on nurses include burnout, physical harm, for example falling asleep when driving home, and negative consequences on home life.9 In response to the evidence that sequential days of 12-h shifts can be detrimental both to patients and nurses, many organizations have instituted the Institute of Medicine’s recommendation to limits nurses’ work hours to 12 h in a twenty-four hour period and no more than 60 h in a week.11 In practical terms, this means that nurses can work 2 sequential days of 12 h shifts with one or two days off before returning to work. Thus there is a high likelihood that patients will be cared for by a number of nurses during their hospital stay. Last, with a significant proportion of nurses older than 4012 and higher acuity caseload, the 12-h shift is not a ‘one size fits all’. Older nurses need longer recovery times from the physical, cognitive and psychological demands of their work,12,13 and are also at greater risk for acquiring work-related injuries.13 Strategies to enhance consistent nursing assignments Twelve-hour shifts are likely here to stay because they fit the lifestyle needs of so many nurses. We will continue to have a nursing workforce shortage. Finally, our hospital patient population will continue to age with concomitant higher vulnerability and need for enhanced vigilance. Our challenge then is to determine creative and flexible ways we can deliver cost-effective care to patients using the principles of consistent assignment while maintaining a conducive work environment for our nurses. A therapeutic older adult-hospital fit consists of four dimensions: the social climate, physical design, policies and procedures, and care systems and processes.14 In an integrative review of 66 hospital studies aimed at improving hospital care for older adults, few studies elaborated on care systems and processes and little is known on resource allocation and detailing of what was done to achieve patient, nurse or organizational outcomes.14 With the aging population and ongoing nursing shortage, we will need to identify ways to address consistent assignments and conducive nurse work
environments. Importantly, we need to share our programs and experiences with one another. Kimball and colleagues15 conducted an in depth search and review of 45 existing models of care and profiled five new models of care delivery. Common elements among these successful models were an elevated role played by the RN; greater focus on the patient and role of the patient and family; enhancing patient transitions and handoffs, especially for complex older adult patients; using technology to enhance point of service care, such as pharmacy robots or remote monitoring stations; and ongoing feedback of results. Several sites have devised and implemented successful RNled teams consisting of RNs, licensed practical nurses (LPNs), and unlicensed nursing assistants (UNA).16e18 The studies did not explicate whether team memberships were consistent or varied daily. Nor did they explicate unique roles for aging nurses or varying shift patterns, which may or may not enhance consistent assignments. Utilizing an elevated team approach with established team members would enhance consistent assignment principles by ensuring overlapping team members would know the patient and family. Last, hospitals and units need to examine context-specific aspects of nursing delivery models. This will ensure best approaches to meeting the needs of our older adult patients .. and of our nurses. References 1. Administration on Aging. A Profile of Older Americans 2016. Accessed 22 March 2017 https://aoa.acl.gov/Aging_Statistics/Profile/index.aspx. 2. Inouye SK, Charpentier PA. Precipitating factors for d elirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852e857. 3. Schimmel EM. The hazards of hospitalization. Ann Intern Med. 1964;60: 100e110. 4. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(30):219e223. 5. Boockvar KS, Lachs MS. Predictive value of nonspecific symptoms for acute illness in nursing home residents. J Am Geriatr Soc. 2003;51:1111e1115. 6. Allen SB. The nurse-patient assignment: purposes and decision factors. J Nurs Admin. 2015;45(12):628e635. 7. Sherman RO. The Dilemma with the 12-hour Nursing Shift. Accessed 22 March 2017 http://www.emergingleader.com/12-hournursingshift/. 8. Trinkoff M, Johantgen M, Storr CL, Gurses AP, Liang Y, Han K. Nurses’ work schedule characteristics, nurse staffing and patient mortality. Nurs Res. 2011;60(1):1e8. 9. Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff. 2012;31(11):2501e2509. 10. Agency for Healthcare Research and Quality. Nursing and Patient Safety. July 2016. Accessed 22 March 2017. https://psnet.ahrq.gov/primers/primer/22. 11. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington DC: National Academies Press; 2003. 12. American Nurses Association. Fast Facts. The Nursing Workforce 2014: Growth, Salaries, Education, Demographics and Trends. Accessed 22 March 2017. http:// nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/work force/Fast-Facts-2014-Nursing-Workforce.pdf. 13. Harrington L, Heidkamp M. The Aging Workforce: Challenges for the Health Care Industry Workforce. National Technical Assistance and Research Center to Promote Leadership for Increasing the Employment and Economic Independence of Adults with Disabilities. Accessed 22 March 2017. https:// www.dol.gov/odep/pdf/NTAR-AgingWorkforceHealthCare.pdf. 14. Parke B, Hunter KF, Bostrom AM, Chambers T, Manraj C. Identifying modifiable factors to improve quality for older adults in hospital: a scoping review. Int J Older People Nurs. 2014;9(1):8e24. 15. Kimball B, Cherner D, Joyn J, O’Neil SE. The quest for new innovative care delivery models. J Nurs Admin. 2007;37(9):392e398. 16. Hastings SE, Suter E, Bloom J, Sharma K. Introduction of a team-based care model in a general medical unit. BMC Health Serv Res. 2016;16:245e256. 17. Rudisill PT, Dienemann J, Callis C, Samuelson M, Hardin SR. Care Redesign. A higher-quality, lower-cost model for acute care. J Nurs Admin. 2014;44:388e394. 18. Cann T, Gardner A. Change for the better: an innovative model of care delivering positive patient and workforce outcomes. Collegian. 2012;19:107e113.