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MNA Position Statement
SUFFICIENCY
OF NURSING CARE
I. Introduction
In recent years,
the health care industry has undergone a dramatic transformation in Massachusetts
and across the nation, which has had an equally dramatic impact on nurses as
they attempt to provide safe nursing care to patients in a variety of health
care settings.
This transformation
is characterized by a number of contributing factors, including an increased
penetration of managed care, changes in health care financing (i.e. decreases
in reimbursement for Medicare and Medicaid), deregulation of the industry resulting
in unprecedented competition and consolidation among providers, and the entrance
of for-profit health care providers into the Massachusetts’s health care arena.
These trends have resulted in an increased focus by many providers on market
competition and financial performance. often at the expense of their traditional
mission of providing accessible, high quality health care.
For patients, these
changes have resulted in shorter hospital stays, and more care and treatment
being provided in settings outside of acute care environments. It also has resulted
in a dramatic rise in the acuity level of patients in all health care settings.
Patients entering a hospital today are more intensely ill. In many cases,
patients will leave the hospital and enter home care and nursing home/subacute
care environments in a more compromised condition than in years past.
In this environment
health care providers have adopted a number of strategies to survive and compete
that have had a direct impact on the nursing profession. These strategies are
designed to cut the cost of nursing labor to support budgetary goals. They include
efforts to downsize nursing staffs, resulting in fewer nurses caring for more
patients; or to re-engineer nursing care delivery, resulting in the replacement
of licensed nurses with lower paid unlicensed workers.
For nurses, the
current health care environment has had a negative impact on their ability to
provide adequate nursing care. At a time when patients are sicker and have a
greater need for nursing care, nurses report having less time to provide the
level of care their patients require. The ultimate reality of today's health
care system is that many patients are receiving insufficient nursing care.
Patients cared
for in understaffed environments are at risk for inadequate assessment of their
condition, increased infection rates, skin breakdown, medication errors, inadequate
pain management, falls, and inadequate preparation for discharge. Any or all
of these factors can result in increased length of stay, readmissions, and increased
cost to the patient, family, taxpayer and the health care system (i).
Conversely, there is a positive correlation between an increase in nurse staffing
levels and positive outcomes for patients in all of these areas.
This position statement
recognizes one clear fact: the ability of nurses to deliver the care consistent
with their professional standards is directly related to the number and/or complexity
of the patients they are assigned. Current Massachusetts law/regulations, and
health care provider policies do not provide appropriate guarantees, or the
mechanisms to ensure patients a sufficient level of nursing care. While Massachusetts
Department of Public Health regulations mandate that health care providers provide
"sufficient" nursing care, "sufficient" is not defined in the regulations. It
is hoped that this position statement can serve as the basis for future debate
among policymakers, health care agencies and professionals; and in legislative/regulatory
initiatives to bring about the changes necessary to guarantee all citizens access
to sufficient levels of nursing care.
II. Philosophy
The Massachusetts
Nurses Association believes that each patient in all health care settings is
entitled to, and must be assured of uncompromised safe nursing care delivered
by a licensed nurse. This care commences upon entry into the health care system
and continues throughout the patient's clinical course. It requires ongoing
assessment, planning, implementation and evaluation of a plan of care established
by a Registered Nurse. Nurses have an ethical and legal responsibility to ensure
that their nursing care is delivered at a level that meets recognized professional
standards.
The Registered
Nurse, educated in the art and science of nursing, plans care, maximizes the
patient's ability to respond to the therapeutic plan of care, promotes and provides
for adaptation to chronic illness and disability, and assures comfort and dignity
to individuals and families in all stages of illness. An essential component
of nursing care is a therapeutic nurse-patient relationship based on confidence
and trust.
There must be sufficient
professional nursing staff to enable the nurse to perform these functions as
well as educate other members of the health care team to the optimal plan of
care. The Nurse Practice Act states that the Registered Nurse “shall bear
full and ultimate responsibility for the nursing care which s/he provides to
individuals and groups”(2). Fulfillment of this responsibility is contingent
upon the availability of a sufficient number of registered nurses who are able
and qualified to carry out judgment activities at a level consistent with patient
care needs.
III. Ensuring
Sufficient Nursing Care
In order for the
patient to achieve desired outcomes, nursing must assume responsibility for
assuring that the patient's care is being provided by an educated and licensed
nurse who has the documented competencies to meet the specific health care needs
of the patient in the environment in which the care is being provided. Over
the past two decades, studies have shown that care provided by Registered Nurses
decreases length of stay, decreases patient complications, and increases patient
satisfaction (3).
Characteristics
of Sufficient Nursing Care
- Sufficient
nursing care must include patient assessment, plan of care, ongoing evaluation,
patient education, discharge planning and follow-up care.
- This care must
be individualized to the patent’s specific needs. Lack of nursing presence
may subject the patient to complications, which can increase length of stay
and prolong the need for care.
- The Registered
Nurse must coordinate the patient's care, and when appropriate and necessary
delegate care to other licensed and unlicensed providers.
Minimum Standards for Ensuring Sufficiency of Nursing Care
- The nurse must
have a caseload which allows enough time to provide the needed care.
S/he must be provided a safe work environment, staffing patterns which are
supportive of the care required, the opportunity for continuity of care. In
assignments, educational opportunities that facilitate the development and/or
maintenance of competencies, and the ability to advocate for the patient and
his/her needs.
- Core staffing
should be adequate to assure continuity of care and allow for meeting the
usual and customary patient needs. Factors determining core staffing include
the patient's activity level, their functional capacity for self care, professional
standards, an appropriate professional/non-professional skill mix and past
statistical patterns.
- When unusual
events occur, a plan must be in place to assure that quality-nursing care
continues uninterrupted.
Indicators of Insufficient
Staffing
Indications of
insufficient staffing, include, but are not limited to:
- Frequent use
of mandatory overtime
- Floating of
nursing staff from one unit to another
- Use of temporary
personnel
- Unfilled nursing
staff vacancies
Any or all of these
indicators can lead to fragmentation and decreased continuity of nursing care.
Health Care
System Accountability for Providing Sufficient Nursing Care
The agencies within
the health care system must be held accountable for the provision of the structure
to support sufficient nursing care and achievement of expected outcomes. Each
agency and institution must utilize systems that allocate the optimum level
of nursing resources for the provision of sufficient nursing cart. These systems
must ensure:
- Individual
patient safety needs take precedence over other institutional needs and priorities.
- The administrative
structure allows the nurse to practice according to nationally recognized
professional standards of care.
- There is a
system in place to adjust for variations in workload and staffing requirements.
- A nurse can
fulfill his/her professional and ethical responsibility to achieve resolution
of any issues that may jeopardize patient care. without fear of reprisal.
IV. A Statement of the Patient’s Right to Sufficient Care
Each patient in
all health care settings must be assured of uncompromised nursing care, delivered
by a licensed nurse that meets professional standards. Each patient is
entitled to:
1. Care by a licensed
nurse who has a patient assignment that allows time for completion of nursing
interventions and prevention of complications.
2. Timely assessments
by a professional nurse.
3. Collaboration
with a nurse in developing a plan of care designed to meet their health care
needs regardless of the setting.
4. Participation
by family and/or significant other(s) in developing and implementing a plan
of care
5. An environment
in which the plan of care is able to be carried out effectively.
6. Education related
to their specific health problem(s) and treatment plan.
7. Continuous evaluation
of the patient’s family’s response to the plan of care.
8. Discharge planning
that takes into account the nursing care needs of the patient and the family.
SUFFICIENCY
OF NURSING PRACTICE
DEFINITION OF TERMS
ASSESSMENT:
A systematic dynamic process by which the nurse, through interaction with the
patient, significant others, and health care providers, collects and analyzes
data about the patient. Data may include the following dimensions:
physical, psychological, sociocultural, spiritual, cognitive, functional abilities,
developmental, economic, and life style.
PATIENT:
The recipient of nursing actions. This may be a single person, or a family
or group. Nursing actions towards clients/patients may be directed to
disease or injury prevention, health promotion, health restoration, or health
maintenance.
CONTINUITY OF CARE:
A process that includes patients and significant others in the development of
a coordinated plan of care. This process facilitates the patient’s transition
between settings based on changing needs and available resources.
EVALUATION:
The process of determining both the patient’s progress towards the attainment
of expected outcomes and the effectiveness of nursing care.
HEALTH CARE PROVIDERS:
Individuals with special expertise who provide health care services or assistance
to patients. They may include nurses, physicians, psychologists, social
workers, nutritionists/dietitians, and various therapists.
PLAN OF CARE:
Comprehensive outline of care to be delivered to attain expected outcomes.
SIGNIFICANT OTHERS:
Family members and/or those people significant to the patient.
STANDARDS:
Authoritative statements that describe a competent level of clinical nursing
practice demonstrated through assessment, diagnosis, outcome identification,
planning implementation and evaluation (4).
LICENSED NURSE:
Registered Nurse or Licensed Practical Nurse as defined in 244 CMR.
PROFESSIONAL NURSE:
Registered Nurse.
REGISTERED NURSE:
Registered Nurse is the designation given to an individual who is licensed to
practice professional nursing, holds ultimate responsibility for direct and
indirect nursing care, is a graduate of an approved school for professional
nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L.
c. 112. Included in such responsibility is providing nursing care, health
maintenance, teaching, counseling, planning, and restoration for optimal functioning
and comfort of those they serve.
UNLICENSED PERSON:
A trained, responsible individual other than the qualified licensed nurse who
functions in a complementary or assistive role to the qualified licensed nurse
in providing direct patient care or carrying out common nursing functions.
The term includes, but is not limited to, nurses, aides, orderlies, assistant,
attendants, technicians, home health aides, and other health aides. (244 CMR
3.051)
REFERENCES
1. American Nurses
Association 1997 Implementing Nursing’s Report Card. A Study of RN Staffing
Length of Stay, and Patient Outcomes: Washington, D.C., Author.
2. The Commonwealth
of Massachusetts, Secretary of State, Regulation Filing and Publication:
Regulation 244 CMR 3.01, Board of Registration in Nursing, 1991.
3. Shindul-Rothschild,
Judith, RN, CS, Ph.D., “Patient Care: How Good is it Where You Work?”
American Journal of Nursing, 1996 (March), New York, New York, Lippencott Publishing
Co.
4. American Nurses
Association (1191) Standards of Clinical Nursing Practice: Washington,
D.C., Author.
Approved
by BOD 11/98
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