Evidence-based hospital nurse staffing: the challenges


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35 comments

  1. David Walker

    The mix of health care providers should, and will, continue to evolve. Just as physicians recognize that relinquishing aspects of their traditional role to other providers in the team makes sense (quality, efficiency, cost sense), it is reasonable to reformat and reconstitute the role traditionally played by nurses. So while some nurses’ roles now encompass far greater scope and responsibility than in the past, other roles can and should be transferred to others who by inclination, training and price are better suited to a given situation. %featured%A sad example is that a significant proportion of patients in acute care hospitals no longer need that level of care and are waiting for long term care. While an RN should be in the mix of their care-givers, RPNs and PSWs are the carers those folk need most. Thus it is the mix ratio that requires revision, flexibility and constant evaluation. I am not sure there is very good science on this yet.%featured%

  2. Elaine Maxwell

    We are facing the same issues in the UK. We previously had a second level registered nurse, called enrolled nurse, but this was abolished when RN training changed in late 1980s/early 1990s. At the same time student nurses became supernumary for the first time and unregulated support workers began to deliver most personal care. The recent Francis report into care at Mid Staffordshire Hospital called for support workers to be registered.

    Studies about safe nurse staffing have looked at educational level of RNs in UK but not at the educational level of others in the care team. The trouble in UK is that it is unclear what the RN role is. Many think it is too senior to provide traditional nursing care. As a nurse with a PhD, I don’t want to be moved to more diagnostic roles such as Nurse Practitioner; I want highly educated nurses at the bedside providing the the supportive role and helping people adapt to different health status that I was originally trained to do, but there is clearly a place for a diverse skill mix (as previously provided by student nurses).

    Until we are clear about the role of RNs, it will be hard to be clear about other roles

  3. Linda Silas, President, Canadian Federation of Nurses Unions

    Congratulations to Healthy Debate for profiling this very timely and important issue for Canadians. I would, however, like to challenge the statement made by Dianne Martin in the article that “research linking more RNs to better patient outcomes is ‘dated’,” and that “we don’t really know how that evidence applies today.” This is simply untrue and terribly undermines the excellent research that nurses, economists and health policy experts have been producing in recent years, in Canada and abroad.

    CFNU’s publication Nursing Workload and Patient Care (Berry & Curry, 2012) is full of current evidence that links inadequate nurse staffing to increases in mortality and other negative outcomes for patients. This compilation of research provides a clear understanding of the value that a nurse’s education and training bring to patient care, and offers a clear vision of a future in which nurse staffing benefits patients and nurses while contributing to the financial viability of our health system. We urge you to read the evidence and decide for yourself.

  4. Linda Wilhelm

    We should be asking patients about the quality of care they receive from nurses regardless of whether they are RN’s or LPN/RPN’s. I have had 14 surgeries in the past 14 years and have had good and bad nurses of both persuasions. Patients need caring and attentive nurses who respond to a call bell when they need to use the bathroom, a basin when they are nauseous, pain medication in a timely manner and sometimes just a bit of reassurance that everything will be fine. At first glance it would seem that RN’s have far more education than LPN’s, the reality is that LPN’s go to school five days a week, eight hours a day for ten months for a two year program. The university programs that I have seen are certainly not five days a week, eight hours every day for eight months of the year. We all know that formal education is just the beginning, nurses continue to gain knowledge post graduation as well all do in our chosen fields.

  5. ann vanderbijl

    Perhaps the words -“If money were no object” says it all. Changes to nursing skill mix tends mostly to be driven by financial considerations. Rationalizations are then sought in the research. These post-facto rationalizations often seem to result in a kind of voluntary amnesia about the rationalization that has taken place. Add to the mix the frequent spectre of dysfunctional relationships between RNs and LPNs, and other unintended consequences of uncertain and ever-changing practice environments – and one can begin to understand the etiology of the aforementioned amnesia.

  6. Katherine Popaleni M.A., Q.Med.

    Hospital and other health care employers need to be mindful that mixing these two health care groups is a major occupational change. Change can be challenging at the best of times, for all of us. The changes that occur in our place of employment can be particularly challenging. Research tells us that change and complexity can manifest disagreement and confusion.
    RNs and LPNs/RPNs are different occupational cultures. While their mutual focus is health promotion, they do fulfill different roles, express different values and maintain different focuses.
    It is therefore understandable that conflict and team hurtles are likely to occur when bringing these two cultural groups together. Health care agencies would do well to predict this change and plan for it accordingly. To that end, I would recommend teaching nurse leaders emotional intelligence skills. These skills will equip them to model effective conflict resolution techniques and facilitate communication between members regarding roles, responsibilities, and turf so the focus can remain on quality patient care.

  7. Barb Mildon

    While this article emphasizes health expenditures, the Canadian Nurses Association (CNA) remains concerned that nursing staff mix decisions are being made based on the availability and cost of nursing staff rather than on patient health-care needs and outcomes. Getting the right mix of appropriate direct care staff is the key to achieving positive outcomes for patients, staff and organizations alike.

    Last year, CNA co-authored the new Staff Mix Decision-making Framework for Quality Nursing Care with the Canadian Council for Practical Nurse Regulators and the Registered Psychiatric Nurses of Canada, through funding from the government of Canada’s Foreign Credential Recognition Program. The framework presents an approach to creating the right mix of direct-care staff — specifically, nurses and unregulated care providers — based on evidence-informed guiding principles. It is a resource that helps optimize staff mix to meet the needs of patients, staff and organizations and support efforts to maximize effective teamwork.

    As the authors mention, evidence associates increased RN proportions at the unit and hospital levels with decreased mortality (Sales et al., 2008; Tourangeau, Doran, et al., 2006) and lower rates of failure to rescue (Blegen et al., 2011; Lang et al., 2004). But higher RN proportions have also been linked to a reduction in patient falls (Patrician et al., 2011), medical adverse events (Patrician et al., 2011) and unplanned emergency department visits (Bobay, Yakusheva, & Weiss, 2011).

    CNA strongly advocates for direct-care nursing staff to be included in nursing staff mix decisions as described in the Staff Mix Decision-making Framework for Quality Nursing Care. Additionally, it is vital to create an evaluation framework in order to assess the impact of any staff mix change on the quality of patient care and the nursing practice environment.

    Barb Mildon
    President, Canadian Nurses Association

  8. Elizabeth Rankin

    It only makes sense that nurses who have a longer period of education and training would be the most highly skilled professionals to care for patients. However, there are many other co-existing factors that determine who should or would be the best to care for a patient. While nurses may be able to provide the ‘all encompassing level of care” if money was no object, it would be a waste of dollars and time for nurses to be doing the menial tasks of changing beds, which is what nurses used to do!
    In a perfect setting, regardless of level of care required…urgent, acute or chronic…all patients require proper assessment and only a nurse can do this and then assign others, including OTHER nurses, to care for the level of care required for each patient under the designated team manager.
    Knowledge and skills are important for each level of training. Important to note is this: Each team member must know what the other member is both capable and expected to do and know their limits and know when and how to report what is needed for the patient. The nurse manager for each team must know the staff well enough to assign them to properly assess the needs of the patient. ESSENTIAL, IS THE NEED FOR PATIENT SAFETY PROTOCOL USING PROPERLY DESIGNED CHECK-LISTS. Refer to the Johns Hopkins Model and the Armstrong Patient Safety Models and have “ALL STAFF” [in any health care setting including the administration] take the online course offered through Coursera. Money alone won’t change the system, only effectively educated staff who share the same knowledge and values can make the difference in the lives of patients.

    Elizabeth Rankin BScN [past participant in the COURSERA online course: THE SCIENCE OF PATIENT SAFETY]
    Author: ©THE PATIENT WILL NOW SEE YOU: How Listening to the Patient will Redefine the Patient-Doctor Relationship. [To be published 2014]
    ©PATIENT RECORDED NARRATIVE: and accompanying PRN App also to be published in 2014
    SIDE-EFFECTS:CONNECT™

  9. Chris

    Not all RNs have a 4 year university degree in Canada. Some practicing RNs who obtained their education either before the upgrade to the university requirements or had their education elsewhere where the 2 year community college RN course was still available. Theses same Rns are paid at or near the same wage as the university degree Rns
    My question is how do these RN compare to the university taught RNs and the 2 year lpn? Could it not be argued that the 2 year lpn course offered at the community college level is what replaced the old 2 year community college RN program ? If so why are so many lpn’s not be allowed to practice at their full scope of practise in many Canadian hospitals.
    Rns are taking on more roles that were once considered an MDs only responsibility so it makes sense lpn’s would take on more rns responsibility -All changes that have occurred are due to the on going and advanced educational requirements .

    • Lillian MIller

      There are very few RN’s left who do not have their degree. Many of us worked hard to obtain our post RN degree. In my view the push to get LPN’s to take on their “full scope” has been a push to reduce the wages of nurses by replacing RN’s who had strong unions and pushed for higher wages, with LPN’s who typically have weaker unions and lower wages. As you pointed out LPN’s have the same training as the old RN but with reduced wages.

  10. Nancy Malachowski

    Lets be honest. This is all about the push to pay workers less “to perform functions,” as Stephen Duckett put it, “at equivalent quality.” And finding further “efficiencies” also includes less full-time more part-time employment with no benefits, not to mention the limiting of vacation time.
    Touting evidence based research and tools is merely the strategy used to rationalize and sell this unfortunate trend to pay care providers less for their work…err “to perform functions at equivalent quality.”

    • Stephen Duckett

      In my view it’s not a bad thing for the health system to function as efficiently as possible (bearing in mind ‘efficiency’ should also take into account quality). Burgeoning health costs give those opposed to Medicare the excuse to say it is ‘unsustainable’ and wind back equity. So why is it wrong for nurses to perform sedation/anesthesia if they can do it in selected patients at the same level of quality as physicians but at one quarter or less if the cost? Or for LPNs to do tasks that RNs used to do, at equivalent quality but at a lower pay rate?

      • Nancy Malachowski

        So why is it wrong for nurses to perform sedation/anesthesia if they can do it in selected patients at the same level of quality as physicians but at one quarter or less the cost? In a nut shell, it’s unfair.
        It ignores the Pay Equity Act and the Employment Standards Act 2000 meant to guard against this kind of injustice. Case in point is the recent human rights complaint filed by the Ontario Midwives on these very grounds against the government to demand a pay raise. No doubt the outcome of this case will clarify the question of why it is wrong to pay some persons a quarter or less than what others receive to perform the same service at the same level of quality or better. (LPNs would do well to follow the example of the Midwives.)
        Essentially this is a womens’ rights issue. Why is it deemed these women deserve so much less compensation?

        http://www.labour.gov.on.ca/english/es/pubs/guide/equalpay.php

    • Jan Irish

      You are so right. If nursing was a mostly male profession, they wouldn’t be working part time with no benefits for years and no one would be disputing the salary they make based on the difficulty/requirements of the job.

  11. Kenneth Lam

    Putting boundaries around professions makes job descriptions neat and tidy, but I am still perplexed as to why the duration of formal training makes one person categorically more competent than another at a given task. I think a tremendous confound in any of these studies is that an RN or RPN designation provides only marginal information about the personality traits likely to have greater bearing on quality of care: conscientiousness, intelligence, etc. I would take a motivated RPN over an unmotivated RN any day–likewise, a motivated NP over an unmotivated MD.

    Would the system benefit from greater mobility between the professions? Is there a way to measure these confounds in the context of one of these staffing studies?

  12. Rhonda

    Our 2 year diploma RN program is now the LPN program. We continue to strive to continue our education to provide the best care possible. We need to work as a team to achieve it along with including our Continuing Care Assistants who also play a vital role in good patient care.

    • Crystal

      The two yr RN program is not the same as the two yr LPN program! Let’s not compare apples to oranges. If that was the case the LPN could look after acutely ill patients and not have to have the RN take over that patients care! LPNs only look after patients who are stable. Let’s not get confused!

      • Mel

        Well let’s see now. When I took the the Ontario RPN program back in 2005, the course calender of subjects and required hours was EXACTLY the same as it was for the RN program in 1998. The only exception was an extra 2 months of clinical time. Now this is a comparison of the 2 courses offered at different times but within the same college, however all of my teachers and instructors at that time confirmed that we were all in “the old RN program.” Perhaps RPN programs have changed since.
        I do know that everyday, I see a huge knowledge and clinical skill deficit within RN grads; contrary to the public image presented that “New RNs can work in any setting, in any role (team lead, charge), and with any patient” which is not possible according to the laws of common sense. I have worked on units where the only RNs were new grads and you know who trained them? RPNs. Because having a fresh nurse being trained by another fresh nurse, regardless of degree or diploma, puts patients at risk. I would like to see nurses trained in the same way as police officers: everyone starts at the same level and with experience and intellect, you move through the ranks. This would ensure your charge nurse would be experienced and not be someone who graduated last week.

    • Marjorie

      Our 2 year program was just that. ..2 years…with a two week vacation break….there was no stopping of class in May…..the 4 year university program was crammed into 2 years

      • Anita

        Yes,
        The RN program I took was 22 months, It was 3yrs crammed into two although it was called “the 2 year program” and at the end of it we wrote the same exam as the university RNs to get our license to practice.The back ground knowledge base for the RN and RPN is very different.
        On the units , in practice this is most evident. I have seen a large gap in knowledge of physiology / pathophysiology that translates to an inability
        to recognize subtle but significant changes in condition of patients and often leads to a delay in intervention. As for the older RPNs , their foundational education was only for basic care, their skills are taught by the agency they work for and the depth of knowledge is questionable.

  13. gretch paul

    In my Longterm care job as an RPN, we get paid $15 lesser than the RN’s, where RPN’s do most of the job. Scope of practice and responsibilities are the same. Which I don’t understand. I searched all over the internet, I find no answer. The only answer I get was, that RN’s had the depth and breadth of education. In reality, RPN’s are now performing the same as RN’s the only difference is the title and pay.

    Now if you want to go for RN/BsCN, RPN’s has to have another 3 years of fulltime education? Is there any way to challenge the CNO to provide separate criteria to RPN’s already performing the job of an RN but just titled and paid lesser than an RN? Instead of wasting money, time and effort of things that you already know well of. Besides what they teach you theoretically is not what’s really happening clinically. There should be a better and easier way to upgrade a licence when you are already in the practice setting as you already know the way things work.
    If anyone can give an answer or enlightenment regarding this issue please. And thank you.

    • Crystal

      Again comparing apples and oranges!!! Read above reply comparing RN’s and LPNs.
      If you were and RN you wouldn’t be asking the question you’re asking!

      • Mel

        You would if you had the same education of a Diploma RN, or more education than say an RN that graduated in the early 70’s. Sorry but education does not determine the competencies of a good nurse.

        • Judy

          so if you have the same education as an RN, then why are you not one? Then you could demand the same wages!! And if you are concerned you are not getting paid enough, refuse to do the duties of an RN without a pay raise!! no one is questioning the “good nurse” thing, but there is a difference in focus between LPNs and RNs. At least that was what I was told. No one is “better” at their job than the other.

  14. S Singh

    If government wants to cut health care expenditures the following steps might work:
    1. Regulate (reduce) minimum amount a doctor gets attending a patient in private setting and reduce number of doctors at the hospital.
    2. Reduce salary of high-paid managerial staff
    3. Reduce staff employed to research nursing practices such as staff watching appropriate hand washing, or time response etc
    4. Bring more long-term care facilities so that patients are not waiting at the hospital for their place in LTC
    5. If a patient is on waiting list for long term care, but waiting at a hospital, make them pay nominal charges as they are ready to pay $4000 per month approx for their long term stay (private homes)
    6. No patient should stay in hospital longer than required
    7. Introduce paid meals (for families with income over certain numbers)
    8. Raise money, but raised money should not be used to pay the staff raising money, and this is what actually happens that most of the raised money goes to the management
    9. Cut down maintenance staff
    10. STOP bringing foreign-trained nurses. This is one of the biggest mistake made by our politicians. Why home land-trained nurses should suffer.

    LPNs AND RNs ARE NEVER THE SAME. The period of training, the focus of training, and amount of tuition and duration of training must be respected

    • anonymous

      I agree with you especially #2 and #3. I am always surprised by the ever-increasing number of non-direct-care staff with no idea about nursing trying to tell already far-stretched front line staff how to do their job.

  15. colin macdonnell

    Where we are (in Canada) both the payer and provider of care, there is NO excuse for the short-sighted comments like “Gordon’s”. When outcomes are not as good as they can be the payer suffers. When staffing issues, professional conflict, and never ending over burdening on RNs continues the providers suffer. We should look to work life balance models and Magnet models to solve these issues. Where the expense of better staffing far outweighs less optimal outcomes. NO excuse!

  16. Elizabeth Melnyk Tkaczyszyn RN,BScN,CEN,GNC

    Thank you for the informative article.
    My question is related to Emergency Department care center.Patient arrive to ED are assessed by Triage RN as CTAS Level 3. CTAS Level 3 patient’s as defined “condition that can potentially progress to a serious problem requiering intervention.” The care center has a staffing mix of one RPN and 2-3 RN’s on a given 12 shift. The care center Lead is assigned to the RPN not to the RN’s.
    When questioned the organization’s management leadership team, the response was the Lead assigned RPN is looked at as a Flow lead.Responsibity is to bring patients into care areas, monitoring the patients lab results,diagnostic interventions and then also directs the UCC,Lab Tech. Manages the patient/charts for reassessment. This RPN also collaborates with the ED Charge Nurse with any changes that are needed related to patient’s admissions,treatment plans, changes in condition.
    I am requesting from you your viewpoint of this assignment mix, also requesting direction as to where this can be further discussed ?CON,RNAO for clarification and raised concern. One Lead RPN with 1-3 RN’swithin their scope but under a Flow/Lead RPN.
    Thank you for your follow up,
    Liz

  17. Robyn H

    This is an absolutely biased article. Some of the best nurses I’ve ever worked with are RPNs. No matter the level of eduction, it’s experience in the field that makes the nurse. A piece of paper will not dictate the quality of nursing that one will provide. This goes without saying that RNs are obviously well educated people, but that does not necessarily mean that every RN will be a good, knowledgeable nurse, which is why it also doesn’t mean that RPNs can’t deliver the same quality care than an RN would.

  18. Jan Irish

    RNs have to have good enough marks to get into to a Bachelor of Nursing program. Just like Doctors have to have good enough marks to get into Med School. Then they go through intensive training to become an RN. RPNs are trained at community colleges and it is an easier, though not an easy program to get into. There are extremely competent RPNs and RNs but they are different jobs. Just as there are great and not so great doctors. Many duties at a hospital can overlap, that goes without saying. Most nurses after going to university and through clinical training work part time and get no benefits. Hospital administrators and doctors have no such problem. I am neither a nurse nor an RPN, but I can’t for the life of me think why anyone with the brains to be a nurse stays in the profession. They are underpaid as part timers and overworked. Compare to teachers, similar amount of training? IMO we are lucky to have them.

  19. Lillian Miller

    This debate makes me somewhat sad as I feel as if RN’s and LPN’s are in a fight about who is more competent. The issue is that LPN’s are being given more responsibility and becoming the new RN’s but at a lower rate of pay. RN’s fought hard to be taken seriously and receive a fair wage. It makes me sad that this is being devalued. If this was a male dominated profession, no one would question our right to make the wage we make. When I listen to LPN’s talk about their role, it feels as if they are competing with RN’s and trying to prove they are just as qualified. This is counter productive. LPN’s should be putting their energy into asking for adequate compensation for the job they do not trying to prove they are just as qualified as an RN to do the job.

    • Bjones

      I agree with you Lillian…well said. I am a RPN

  20. Elizabeth Stewart

    I have been a proud RPN (RNA) since 1974 (over 42 years). I have withstood the comments from people who would say things like “why don’t you become a real nurse”? I was thrilled when the college of nurses said that “nursing is a profession with two categories – RN and RPN”. I never understood the bashing that RPNs withstand from RNs and the education system. After taking a leave to raise my children, I took the New Start Nursing Course at McMaster University. Much of the material supplied was from ONA. I was enraged. I wrote letters to the university, CNO and RPNAO. I met with a representative of RPNAO at that time and the feeling was that since 2003 was the last time this course would be offered, then the problem would go away.
    I am writing to tell you that the problem has not gone. I am about to finish the BScN program. I took it for pragmatic reason which I will not go into here but you need to know that RPN bashing and picturing RNs as prima donnas is alive and well. The universities do not teach BScN students that RPNs are their partners not their enemy. My stomach churns when I hear students relate how they can hardly wait to start work and to teach RPNs how to be nurses. The professors do not even know how to relate RNs to RPNs.
    I am at the University of Windsor. The local hospital is about to lay off many RNs. The rhetoric is that the clients are at risk because the unskilled RPNs are taking over. The university actually allowed ONA to use our website to further propagate their agenda. Do you know of any other union who is given voice on an official academic website?
    I want to make a difference.
    Where is that research to prove that RPNs are part of the solution?
    We need a strong voice. We need to be visible. When the media seeks out a health issue query, we need to also weigh in not just the RNs. We need up to date research to support the fact that RPNs are a safe and viable alternative to RNs in many if not most areas of active care.
    I graduate in June. I want to be part of this movement. I would love to be part of a strategy committee to make RPNs more visible and recognized as one of two categories of nurses who can be counted upon to give exceptional and intelligent care.
    Elizabeth Stewart

    • Rachel

      This is a highly complex issue, not as simple as the division between RN’s and LPN’s. Many of the staffing replace to are not preceded by any education on why staffing changes are being made- and as such this boils down to a “money issue” in the minds of many acute care workers- creating animosity between these two valuable professions. I am a nursing student- and the first question I am always asked? Are you an RN or LPN student? I am an RN student, currently working as an HCA on a unit that is divided into about 60% LPN’s and 40% RN’s.
      In response to previous comments that the university degree gets all summers off, and the LPN degree is the same crammed into two years because they are in school 5 days/ week for ten hours. This is completely untrue. Upon completion of my degree I will have over 2000 hours of clinical experience in a vast spectrum of disciplines. Having over 150 hours in each mental health, seniors health, maternity, pediatrics, community health, as well as over 400 hours in adult health.
      I am in school 5+ days a week, currently writing exams and papers once a week, as well as completing 24 clinical hours per week, and all of the study time that accompany’ this workload. Throughout my experience, LPN’s have been some of the best teachers I have had, and RN’s some of the worst. I can also attest to the reverse. Saving money IS not the biggest factor in an efficient system. LPN’s are incredible, educated, and competent individuals, they have a variety of experience- and in an acute setting can be difficult to distinguish from an RN, because if their expanding scope.
      However, for the most part. The bigger picture determinants of health, systemic barriers, balancing act between efficacy(positive patient outcomes) and efficiency(reducing spending by replacing RN’s with LPN’s) is lacking from their education. There is a bigger patient picture that is much more complex than simple acute skills and creating positive patient outcomes for a hospital stay. There needs to be positive changes to patient lifestyles, determinants of health, very acute skill sets, and identification of systemic barriers and gaps to prevent the revolving door care we too often see.
      This is where your RN’s come in. This is where our education has a wider breadth and depth that doesn’t come simply from completing hours of work in a hospital setting. This is where the education needs to occur to the public, to the RN’s and to the LPN’s. These jobs are BOTH valid, and BOTH necessary. There is no superiority of one over the other there is a difference, and as such a corresponding and valid difference in compensation. This educational component is lacking in that our service ads show that the LPN program lets you “be a nurse faster” and then a corresponding frustration when you don’t receive the same pay for the same job. They are not even remotely the same on a community and systems level, and this is for a variety of reasons.

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