The intent of this position statement is to reaffirm the nursing profession’s responsibility to monitor staffing effectiveness for protection of the public from unsafe and ineffective nursing practice, particularly during times of a nursing shortage.
It is the position of the New York State Nurses Association that:
Nurse staffing is a matter of major concern because it greatly affects patient safety and quality of care. During a nursing shortage, the delivery of safe, quality patient care can suffer, as the tendency is to create short-term fixes to workforce demands, which ultimately fail to address the real problems. Due to the complex nature and inability to isolate single factors or solutions to this nursing shortage, a systems perspective provides the greatest depth and understanding of the relationship between multiple variables, which incorporate issues in education, health delivery systems and the work environment. Furthermore, the impact of reimbursement, legislation, regulation and technological advances provide for a full appreciation of the nursing workforce shortage complexity (National League for Nursing, 2001).
The number of nursing staff available to provide in-patient nursing care is linked to patient safety by substantial and growing number of research studies (Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety, 2003). Nurse staffing ratios are directly related to patient outcomes. Adverse patient outcomes that are directly related to ineffective nurse staffing include urinary tract infections, upper gastrointestinal bleeding, longer hospital stays, shock, failure to rescue, and 30-day mortality (Needleman, Buerhaus, et al., 2002). Effective staffing reduces the occurrence of adverse patient outcomes, and JCAHO (2004) describes effective staffing as, “…providing optimal numbers of competent personnel with the appropriate skill mix to meet the needs of an organization’s patients based on their mission, values, and vision” (p.58).
History has revealed that there is a predictable trend to deregulate and substitute lesser-prepared persons in an attempt to resolve a nursing shortage. In an effort to find a solution to staffing issues, organizations have begun to rely more heavily on supplemental/temporary nursing services personnel, on-line bidding for shifts and foreign nurse recruitment.
It is important to determine between the value and risk associated with on-line bidding for shifts. Systems in which the employer permits internal RNs to choose to bid for hours at their standard rate of pay or for overtime pay are an appropriate strategy that provides the nurse with a fair choice and provides the patients with quality and safe care. Internal personnel are familiar with the facility, current policies and patient population. On the contrary, a system in which hospitals set a maximum rate of pay and internal or external RNs bid for shift pay until the lowest bid prevails exploits nurses and could lead to patient harm (Trossman, 2004). On-line bidding for shifts, not pay, is a technologically advanced method of creating an internal float pool, which is a safer choice for patients and protects nurses’ rights.
According to the National Council of State Boards for Nursing (NCSBN), both domestic and international nurses must comply with standards and regulations governing the practice of nursing. Each registered nurse hired or contracted to work in an organization must be held to the same standards, competencies and expectations (National Council of State Boards of Nursing, 2003). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has discovered that many organizations only include their full-time and direct-care staff members in their competence assessment process, which is unacceptable and not in compliance with JCAHO standards. JCAHO requires that leaders of healthcare organizations be responsible for developing mechanisms to ensure both initial and continuing competence assessment of all individuals providing care in the organization (Joint Commission on Accreditation of Healthcare Organizations, 2004). Any reduction in requirements may lead to increased errors, risk of patient harm, and decreased public confidence (National Council of State Boards of Nursing, 2003).
JCAHO has indicated that staffing should be a priority focus for organizations. An excellent approach to ensure that a facility has appropriate registered nurse staffing is to, “…develop quality staffing plans, monitor staffing level mix, and competency, cross train staff to help ensure staffing adequacy, delegate (assign) duties appropriately, regularly assess staffing plans, limit the use of mandatory overtime to emergency situations, regularly review work schedules, and assess staffing effectiveness” (JCAHO, 2004, p.198). In New York State, the hospital code stipulates that the chief executive officer, “…develops and implements personnel policies and practices with regard to at least the following: …(3) the orientation of all new employees to the hospital and to hospital and personnel policies; (4) the development and implementation of a written plan for in-service training, including orientation and training for the governing body” ("Official Compilation Codes, Rules and Regulations of the State of New York").
To ensure the delivery of safe, quality care, both healthcare organizations and the nursing profession must collaborate to evaluate and monitor the best possible staffing models and methods to maintain competence. It is a registered nurse’s professional responsibility to ensure that the public receives safe and accessible health care. Patients are entitled to safe quality care even during a shortage and the profession has historically accepted and will continue to accept this responsibility (American Nurses Association, 1992). Registered nurses are also entitled to a supportive work environment and dedicated measures to alleviate overload and stress. The Code of Ethics for Nurses with Interpretative Statements declares that, “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth” (American Nurses Association, 2002, p.18).
In conclusion, coordinated efforts in the healthcare arena to provide quality nursing care and to ensure an ample supply of nurses in the future will serve both the public and nursing’s best interests. It is of utmost importance that professional and regulatory bodies uphold existing professional and legal standards regardless of supply and demand issues and seek ways to improve the work environment to increase registered nurse retention.
Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.
Approved by the NYSNA Board of Directors, May 18, 1978 and September 17, 1987.
This position statement replaces: Use of Supplemental or Temporary Nursing Services
Last approved by the Board of Directors on March 9, 2005.
American Nurses Association. (1992). Position statements: Joint statement on maintaining professional and legal standards during a shortage of nursing personnel. Retrieved December 24, 2004, from http://www.nursingworld.org/readroom/position/joint/jtshort.htm
American Nurses Association. (2002). Code of ethics for nurses. Washington, DC: Author.
Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety. (2003). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.
Joint Commission on Accreditation of Healthcare Organizations. (2004). Management of human resources. In CAMH: Comprehensive accreditation manual for hospitals (pp. HR-1 - HR-12). Oakbrook Terrace, IL: Joint Commission Resources.
Joint Commission on Accreditation of Healthcare Organizations. (2004). Priority focus area: Staffing. In The Joint Commission guide to priority focus areas (pp. 191-201). Oakbrook Terrace, IL: Joint Commission Resources.
Joint Commission on Accreditation of Healthcare Organizations. (2004). Shared visions - new pathways: Essentials for healthcare. Oakbrook Terrace, IL: Author.
National Council of State Boards of Nursing. (2003). Position Statement: Foreign (International) nurse immigration. Retrieved January 4, 2005, from http://www.ncsbn.org/news/statementstestimony_news_statements_positions.asp
National League for Nursing. (2001). Tri-Council for Nursing policy statement: Strategies to reverse the new nursing shortage. Retrieved December 27, 2004, from http://www.nln.org/aboutnln/news_tricouncil2.htm
Needleman, J., Buerhaus, P., Matke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346, 1715-1722.
Official Compilation Codes, Rules and Regulations of the State of New York., Title 10 (Vol. C) Health, Part 405 Hospital Minimum Standards, Section 405.3 Administration.
Stanton, M. A. (2004). Hospital nurse staffing and quality of care. Research in Action (Agency for Healthcare Research and Quality), Issue #14.
Trossman, S. (May/June 2004). Move over eBay? A Potential trend involving bidding for shifts online. The American Nurse, 36(3) 1,8,12.
For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.