Financial and Human Resources Essay Assignment

Leadership Theory

• Lynch, B. M., McCance, T., McCormack, B., & Brown, D. (2017). The development of the Person-Centred Situational Leadership Framework: Revealing the being of person-centredness in nursing homes. Journal of Clinical Nursing, 27​(1-2), 427–440.

• • This article presents an application of the Person‐Centred Situational Leadership Framework and its relevance to complex care environments.

The development of the Person-Centred Situational Leadership Framework: Revealing the being of person-centredness in nursing homes

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Abstract

Aims and objectives

To implement and evaluate the effect of using the Person-Centred Situational Leadership Framework to develop person-centred care within nursing homes.

Background

Many models of nursing leadership have been developed internationally in recent years but do not fit with the emergent complex philosophy of nursing home care. This study develops the Person-Centred Situational Leadership Framework that supports this philosophy. It forms the theoretical basis of the action research study described in this article. Financial and Human Resources Essay Assignment

Methods

This was a complex action research study using the following multiple methods: nonparticipatory observation using the Workplace Culture Critical Analysis Tool (n = 30); critical and reflective dialogues with participants (n = 39) at time 1 (beginning of study), time 2 (end of study) and time 3 (6 months after study had ended); narratives from residents at time 1 and time 2 (n = 8); focus groups with staff at time 2 (n = 12) and reflective field notes. Different approaches to analyse the data were adopted for the different data sources, and the overall results of the thematic analysis were brought together using cognitive mapping.

Results

The Person-Centred Situational Leadership Framework captures seven core attributes of the leader that facilitate person-centredness in others: relating to the essence of being; harmonising actions with the vision; balancing concern for compliance with concern for person-centredness; connecting with the other person in the instant; intentionally enthusing the other person to act; listening to the other person with the heart; and unifying through collaboration, appreciation and trust.

Conclusions

This study led to a theoretical contribution in relation to the Person-Centred Practice Framework. It makes an important key contribution internationally to the gap in knowledge about leadership in residential care facilities for older people.

Relevance to clinical practice

The findings can be seen to have significant applicability internationally, across other care settings and contexts.

What does this paper contribute to the wider global clinical community?

• This study makes an important key contribution to the gap in knowledge about leadership in residential care facilities for older people.
• A model of leadership is presented (the Person-Centred Situational Leadership Framework) that is facilitative, enabling and person-centred and is the first of its kind in residential care.
• This study illustrates that engagement in a facilitated critical reflective process is fundamental to the development of person-centred leadership and more person-centredness among care staff.

1 INTRODUCTION

The endorsement of a leadership approach that will change the culture of care for older people living in nursing homes is an important agenda internationally. There are, however, few robust studies in the literature that explore the correlation between transformational leadership and effective nursing care in long-term care facilities for older people (Lynch, 2015). Although several models of leadership have been developed for acute care settings and for management and policy situations, many of them are not appropriate for nursing home contexts (McCormack, Roberts, Meyer, Morgan, & Boscart, 2012). Contemporary nursing home care espouses the concept of “person” and “personhood” and is increasingly influenced by the philosophy of “household,” where the physical environment of the nursing home and all its features are designed to mirror a true home for the residents (Chapin, 2006; Shields & Norton, 2006; Thomas, 2004). The development of a theoretical framework of situational leadership in residential care for older people (Lynch, McCormack, & McCance, 2011) can be considered as an approach that supports this philosophy—the Person-Centred Situational Leadership Framework (PCSLF). The framework integrates person-centred theory as depicted in the Person-Centred Nursing Framework (McCormack & McCance, 2006, 2010, 2017) with situational leadership theory (Hersey & Blanchard, 1982, 1997). The PCSLF emphasises the key behaviours and contextual variables involved in the process of developing others to accomplish the optimum outcome of effective person-centred practice. The framework was used in an action research study in residential care as the foundation for developing and facilitating a leadership intervention programme for six leaders. The purpose of this study was to report on one aspect that emerged from this complex action research study, focusing on seven core themes/attributes that contribute to our understanding of person-centred situational leadership in residential care settings. Financial and Human Resources Essay Assignment

2 BACKGROUND

The nursing home, as a community for older people living together and a place where staff come to work, embodies a complex array of relationships, interactions and connections. This complexity often leads to a control model of management and leadership that can be observed in the way staff schedules and routines control the space, the time and the people in the building (Brown Wilson, 2009; Grant & Norton, 2005). Over the past 10 years, there has been a significant change in the philosophy of nursing home care for older people internationally (Ragsdale & McDougall, 2008). In the USA and Canada, this change stemmed from the recognition that older people living in nursing homes were lonely, bored and helpless (Thomas, 2004). Several culture change models advocating the radical transformation of nursing home care were developed around the same time and included Wellspring (Stone, Reinhard, Bowers, Zimmerman, & Phillips, 2002), Eden Alternative (Thomas, 2004) and the Household Model (Shields & Norton, 2006). To date, there is a lack of empirical evidence in the literature to demonstrate the impact this culture change movement has had on the quality of life of the residents living in nursing homes (Petriwskyj, Parker, Brown Wilson, & Gibson, 2015).

Consistent with international reviews (Bamford-Wade & Moss, 2010; Bowles & Bowles, 2000; Govier & Nash, 2009; Thyer, 2003), recommendations from a number of reviews in the Republic of Ireland (HIQA, 2009; Murphy, O’Shea, Cooney, Shiel, & Hodgins, 2006) all call for a change in the culture of care and a move to a more person-centred approach led by a transformational nurse leader. More recently, the Francis report (2013) highlights the need for the nursing profession to develop skilled nurse leaders who will enable the delivery of effective person-centred care.

2.1 Culture change and person-centredness

There are opposing views in the literature as to how the culture of an organisation can be changed. Some writers suggest that the culture can be manipulated by the leader (Bate, 1994; Schneider, 1994), while others describe a shaping and moulding of the culture by the actions and reactions of the leader, and the leader in turn being shaped and moulded by that culture (Bass & Avolio, 1994). Within these opposing views, a consensus still exists suggesting that leadership and culture are strongly interwoven (Schein, 1992). With reference to nursing homes, culture change involves the complete transformation of the institutional practices, routines and schedules that govern the delivery of care to residents—in other words, a person-centred culture. McCormack and McCance (2010) define person-centredness as:

an approach to practice established through the formation and fostering of therapeutic relationships between all care providers, older people and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development. (McCormack & McCance, 2010; p. 31)

For over a decade, the literature on nursing leadership has demonstrated the endorsement of transformational leadership as the preferred style in leading nursing through a constantly changing healthcare environment (Bamford-Wade & Moss, 2010; Bowles & Bowles, 2000; Govier & Nash, 2009). To date, very little work has been performed to make a correlation between transformational leadership and effective nursing care in nursing homes. McCormack et al. (2012) carried out a review of several new models that claim to have a person-centred focus and aim to de-institutionalise care settings for older people. In their review, the authors explore the implications of these models for the role of the registered nurse in residential care and caution against their implementation in the absence of a clear understanding of the concept “person” and “personhood.” McCormack et al. (2012) argue that for an effective person-centred culture in nursing homes to develop, the personhood of all persons (residents, staff members and family members) needs to be honoured and respected so that meaningful relationships are created within a supportive context that enables person-centred care to take place. Nolan, Davies, Brown, Keady, and Nolan (2004) conclude that “relationship-centred care” is a more suitable term (Nolan et al., 2004, p. 47). However, as an understanding of the concept of personhood and meaningful relationships is essential to the implementation of person-centred care, it is apparent that a like-minded view between person-centred care and relationship-centred care exists. The Person-Centred Situational Leadership Framework (PCSLF) in nursing homes (Lynch et al., 2011) can be considered an approach that supports these principles. Financial and Human Resources Essay Assignment

2.2 An overview of the Person-Centred Situational Leadership Framework (PCSLF)

Working from the premise that transformational leadership is situational leadership enacted within the Person-Centred Nursing (PCN) Framework, a theoretical framework of situational leadership in nursing homes was developed that brings together previous empirical research by McCormack and McCance (2006, 2010, 2017) and Hersey and Blanchard (1982, 1997)—the PCSLF. This action research study was used to demonstrate the use of the framework.

The PCSLF focuses on the leader’s ability to diagnose the performance, competence and commitment of the follower. By adopting a flexible approach, the leader modifies their style of leadership to align it with the developmental level of the follower. Blanchard (2007) defines the “follower” as:

the person being led by the situational leader (p. 88).

Through the process of “partnering for performance” (Lynch, 2015), the situational leader diagnoses the follower’s effectiveness in delivering person-centred care. This is established by determining where the follower sits on the developmental continuum in relation to the five prerequisites of professional competence, commitment, interpersonal skills, clarity of values and beliefs and knowledge of self, outlined in the Person-Centred Practice Framework (McCormack & McCance, 2017). For example, in relation to performing a specific task to deliver care, the leader and the follower agree on the diagnosis of the follower’s developmental level, ranging from D1 (enthusiastic beginner) through to D4 (self-reliant achiever). Using a person-centred approach, the situational leader adopts a leadership style, ranging from S1 (directing) through to S4 (delegating) and aligns it to the follower’s developmental level. By combing high and low supporting behaviours with high and low directing behaviours, the situational leader takes the follower through the developmental levels in order to manage the care environment and deliver effective person-centred care (Lynch et al., 2011). Financial and Human Resources Essay Assignment

3 THE STUDY

3.1 Aim

The main aim of the study was to implement and evaluate the effect of using the PCSLF to develop person-centred care within nursing homes.

3.2 Objective

• To use the PCSLF as the foundation for developing and facilitating a leadership intervention programme for six leaders.

3.3 The context

The research study was undertaken in the Republic of Ireland in established privately operated nursing home. The nursing home had 84 residents who lived in three households, within the facility. Each household mirrored a normal home environment, with its own kitchen, sitting room, dining room, bathrooms and bedrooms. The services provided in the nursing home included residential care, nursing care for the frail older person and care for the person living with dementia. The leaders in the nursing home were the director of nursing (DON) and her assistant, the care manager (CM). Each household had a clinical lead (a registered nurse) and a house lead (a senior member of care staff), and they reported directly to the DON and CM. At the time of recruiting the leader participants, there were six leaders in the nursing home: one household did not have a clinical lead appointed and another household did not have a house lead appointed. All the leaders in the nursing home (n = 6) participated in the study: Rose (DON), Bell (CM), Dot and Jen (clinical leads) and Polly and Iris (house leads). These are pseudonyms for the leaders. Financial and Human Resources Essay Assignment

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4 METHODS

The study adopted an action research approach similar to the process described by Lewin (1946/1948; p. 206):

It proceeds in a spiral of steps, each of which is composed of a circle of planning, action and fact finding about the results of the action.

A qualitative approach to the evaluation of the implementation of the PCSLF was adopted. This approach focused on gaining a deep understanding of the relationship between situational leadership processes and how these processes are operationalised in the context of person-centred culture change.

4.1 Data collection

In order to gain a deep understanding of leadership practices and principles and how these were understood by team members, residents, managers and the leaders themselves, the data came from several sources: Financial and Human Resources Essay Assignment

• The Workplace Culture Critical Analysis Tool (WCCAT; McCormack, Henderson, Wilson, & Wright, 2009) is a nonparticipatory observation tool that uses combined practice observations and critical dialogue approaches to data collection. It was used in the study to analyse the culture of the practice settings where the leaders work. The tool itself adopts a holistic and person-centred perspective and the observation criteria are specifically designed to explore the processes of practice and the extent to which they reflect person-centred principles, team relationships and the way these do or do not support person-centred practice.
• Critical and reflective dialogues between the lead researcher (BL) and each of the six leaders helped to generate a deep understanding of the culture and the experiences of the leader participants. These conversations were initiated during initial workshops, debriefing following observations of practice and monthly meetings with leaders.
• Narratives from residents at time 1 and time 2 of the study. The main aim of the narration was to gain an understanding of how residents perceived leadership in the nursing home. At the commencement of the narrative interview, the resident was given an explanation of the purpose of the study and the main focus of the narration was identified. Bauer (1996) suggests that the narrative interview uses an ordinary day-to-day method of communication that combines the telling of a story with listening and in so doing, gathers data in a natural way.
• Focus groups held with staff at time 2. Participants were asked to focus on what they saw as the particular skills required by the leader to lead person-centred care effectively and how they felt the PCSLF had or had not contributed to the developmental level of the team in the household.
• Reflective field notes helped tie the whole process together. The reflective field notes by the lead researcher (BL) were structured to capture a description of the experience, the issues that arose during it, the feelings about the experience, what could have been changed and the learning from the experience.

4.2 Sample/study participants Financial and Human Resources Essay Assignment

The study participants were recruited from the staff and residents in the nursing home. Different approaches to sampling were adopted dependent on the method of data collection. For the observations of practice, a convenience sampling strategy was used to include all team members as key participants during the negotiated time period of each observation. Convenience sampling was used for the resident narratives at time 1 and time 2 of the study. A purposive sampling strategy was used to recruit six participants for the staff focus group. The participants were recruited from across the three households and included a registered nurse and a carer from each household. All six leaders in the nursing home were included as a convenience sample for the focus group with leaders

Finances

• Johnson, J. E. (2017). Financial terms 101. American Nurse Today, 12(4), 16–18. https://www.americannursetoday.com/financial-terms-101/

• • This resource provides definitions and brief explanations about key financial terms that you will need to know.

Human Resources

• Carlisle, B., Perera, A., Stutzman, S. E., Brown-Cleere, S., Parwaiz, A., & Olson, D. M. (2020). Efficacy of using available data to examine nurse staffing ratios and quality of care metrics. Journal of Neuroscience Nursing, 52(2), 78–83.

• • This article looks at measurable outcomes in relation to the nurse-to-patient ratio.
• Olley, R., Edwards, I., Avery, M., & Cooper, H. (2019). Systematic review of the evidence Related to mandated nurse staffing ratios in acute care hospitals. Australian Health Review, 43, 288‒293.

• • This article evaluates and summarizes current research on nurse staffing methods and relates those to outcomes.

Efficacy of Using Available Data to Examine Nurse Staffing Ratios and Quality of Care Metrics Financial and Human Resources Essay Assignment

ABSTRACT

BACKGROUND: Nurse staffing ratios impact both the quality and safety of care on a particular unit. Most hospitals have access to a large volume of nurse-sensitive outcomes. We hypothesized that these data could be used to explore the impact of changing the nurse-to-patient ratio on patient-reported outcomes, nurse satisfaction scores, and quality of care metrics. METHODS: Retrospective data from hospital resources (eg, Press Ganey reports) were linked to daily staffing records (eg, assignment sheets) in a pre-post study. Before September 2017, the nurse-to-patient ratio was 1:1.75 (pre); afterward, the ratio was reduced to 1:1.5 (post). RESULTS: Press Ganey National Database of Nursing Quality Indicators scores were improved, staffing turnover rates were reduced, and falls were linked to periods of high nurse-to-patient ratios. CONCLUSION: This study shows the efficacy of using readily available metrics to explore for associations between nurse staffing and nurse-sensitive outcomes at the nursing care unit level. This provides a unique perspective to optimize staffing ratios based on personalized (unit-level) metrics.

Nurse managers are exposed to a diverse, and often overwhelming, amount of data from which they are expected to derive, track, and store information. Quality of care metrics, financial balance, nurse satisfaction, and patient satisfaction are a few of the more common constructs that nurse managers encounter as nurse-sensitive outcomes. Staffing levels are hypothesized as one of many predictor variables that may impact the aforementioned nurse-sensitive outcomes.1 Because the nurse-to-patient (RN:PT) ratio must be individualized, staffing ratios vary significantly by unit type (eg, ambulatory clinic vs intensive care).2 Given that each nursing unit has unique properties, there is an unmet need in the methods by which nurse managers can evaluate the impact of individualizing staffing ratios to meet their unit needs. In addition, many times, staffing changes are made without tracking data and outcomes for both patients and staff. This study examined the efficacy of using discrete, readily available data to explore the impact of changing the RN:PT ratio on patient-reported outcomes, nurse satisfaction scores, and quality of care metrics. Financial and Human Resources Essay Assignment

Background

The RN:PT ratio is an expression of the number of nurses available to provide direct care to a number of patients. The RN:PT ratio (ie, staffing ratio) impacts patient quality, nurse satisfaction, and patient satisfaction.3,4 Although this ratio is a common topic of discussion for nurse managers,4 nursing administration, and news media,5 there is a relatively small amount of data-driven evidence linking nurse-sensitive outcomes to various RN:PT ratios within a defined nursing unit. This is especially true of specialty care units.Analyses performed at the hospital level (eg, the hospital is the unit of analysis) demonstrate that the RN:PT ratio impacts the quality of care provided to patients and directly influences the safety of care provided, with higher RN:PT ratios being preferred.6 The ratio of nurses to patients depends on the acuity of the patients (eg, there is a different RN:PT ratio need in the intensive care unit [ICU] as compared with the rehabilitation unit). Kane et al7 completed a systematic review in 2007 that showed that increasing registered nurse (RN) staffing by 1 additional full-time nurse was associated with a 9% decrease in hospital-related ICU mortality. Increasing the RN ratio by 1 RN per patient day was associated with a decrease in hospital-acquired pneumonia, unplanned self-device removal, respiratory failure, and cardiac arrest in ICUs. In this same review, length of stay was shortened by 24% in ICUs and by 31% in surgical patients by increasing the RN ratio by 1 RN per patient day.7Nursing units are becoming increasingly specialized. Staffing needs must be individualized to patient acuity, staff experience, staff workload, ancillary services and testing, and hourly changes in patient census.8,9 A mismatch in the ratio could result in financial burden or burnout of the nursing staff, resulting in mistakes.10 It is important to include different variables such as patient needs, intensity of patient care needs, and time spent undertaking operational requirements (ie, distance to and accessibility of medications or equipment required for patient care) because these impact the nurse’s time at the bedside. In short, the time required by the nurse to take care of 1 patient should not adversely affect the care of other patients or force a nurse to cut corners while caring for a patient to care for others.10The RN:PT ratio affects staff engagement and the quality of care they are able to provide, as well as having a direct influence on patient satisfaction. Improved nurse staffing has been linked to lower rates of nosocomial complications such as infection, pneumonia, and pressure ulcers.1,11,12 Patients with more staff reported higher levels of confidence in the nurses caring for them and satisfaction with care.13 In addition, increasing the RN:PT ratio decreases nurse workload. The decrease in workload allows the nurse additional time with the patient and care partners, which has been shown to increase patient satisfaction.6Staffing is a common topic for nurse managers and administrators, yet there is little literature to support the impact of changing staff ratios in the neurocritical care unit (NCU) on staff and patient outcomes. Most of the available resources are focused on patient satisfaction scores.14–18 Similar to previous studies examining staffing impact, the population and unit of analysis being used in this study is the NCU. The intervention in this study is a change in the RN:PT staffing ratio.19–21Like many NCUs, ours provides postanesthesia care to neurological surgery patients rather than the postanesthesia care unit. To meet professional guidelines for postanesthesia care, our NCU adheres to the American Society of PeriAnesthesia Nurses (ASPAN) guidelines.22 We reviewed the ASPAN guidelines and compared their recommendations with our practice workflow. With 75% of our average daily census being postoperative, we wanted to provide additional support for the RNs to allow them more time with the patient during the immediate postoperative phase of care. Following ASPAN recommendations gave our NCU an additional 4.3 full-time employees and allowed our nurses more time to recover their patients. Financial and Human Resources Essay Assignment

Methods

This analysis includes both retrospective and prospective data representing staffing ratios and nurse-sensitive outcomes from August 2016 to June 2018. The RN:PT ratio before September 1, 2017, was 1:1.75, at which time the NCU was approved to adjust the RN:PT ratio to 1:1.5. The decision to change the planned staffing ratio was made by the nurse manager based on the evidence summarized previously. The plan was approved by administration (Director of Neuroscience Services) after being presented to the hospital chief nurse executive and chief financial officer (see Supplemental Digital Content 1, available at http://links.lww.com/JNN/A214, and Supplemental Digital Content 2, available at http://links.lww.com/JNN/A215). This staffing change led to a budget alteration for additional full-time RNs to be hired. Data were collected from various sources to determine the impact of the ratio change on staff and patients. The university institutional review board determined the study was exempt from institutional review board review. All data are from a single university teaching hospital NCU and were deidentified. Data analyses were performed using SAS v9.4 (SAS Institute).Staff satisfaction data were abstracted from annual Press Ganey National Database of Nursing Quality Indicators (NDNQI)23 reports. Staffing data were abstracted from daily assignment sheets. Patient satisfaction was abstracted from monthly Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems scores. Quality indicators and infection rates were tracked by the hospital infectious disease department and reviewed monthly; these data were abstracted to provide quality of care metrics.

Results

From August 2016 through August 2017 (preintervention), the mean RN:PT ratio was 1:1.80 on day shift and 1:1.73 on night shift. From September 2017 to June 2018 (postintervention), the mean RN:PT was 1:1.73 on day shift and 1:1.63 on night shift. There was a decrease in the frequency of 1:3 assignments; preintervention, there were 107 times when an NCU nurse was assigned to care for 3 patients (58 on day shift, 49 on night shift) compared with 40 times (18 on day shift, 22 on night shift) during the postintervention period.Nurse satisfaction was examined using NDNQI results. The NDNQI survey response rate was 60% preintervention and 95% postintervention. There was improvement in 5 major NDNQI survey categories, where nurses’ preintervention and postintervention scores increased from the 75th to 90th percentile (Table 1). These categories included the ranking for nurses who felt that they have what they need and they can make a contribution that gives meaning to their life, that staffing and resources were adequate, job enjoyment, nursing foundations for quality of care, and mean practice environment scale score. Staffing turnover (RNs who leave divided by the total number of RNs) was 19.8% for the year 2016–2017, 16.7% for the year 2017–2018, and 5.7% for the year 2018–2019. Financial and Human Resources Essay Assignment

Patient satisfaction was examined by exploring patient responses from Press Ganey surveys. Of 108 completed surveys, 55 were preintervention and 53 were postintervention. This study reviewed 5 Press Ganey quality variables (percentage of response rated the hospital 9–10, response of hospital staff, communication with nurses, hospital environment, and discharge information presented). Of the 5 patient satisfaction variables on the Press Ganey survey, only 1 quality indicator, communication with nurses, increased (Table 2). Statistical analysis was performed on different quality aspects; none of the findings was statistically significant.

Quality of care was examined by calculating the number of falls, catheter-associated urinary tract infection, and central line–associated blood stream infection in the preintervention and postintervention periods. The number of catheter-associated urinary tract infections decreased from 12 to 3. The number of central line–associated blood stream infections also decreased from 1 to 0. Although all 6 falls documented occurred after the ratio change was implemented, these falls occurred on days when the RN:PT ratio was higher than 1:1.5. The hospital-acquired pressure ulcers decreased from 26 before the staffing change to 22 after the staffing change.

Discussion

The data provide compelling evidence to support the efficacy of using discrete and readily available data to examine the impact of nurse staffing on nurse satisfaction, patient satisfaction, and patient outcomes. Whereas general care units flourished, nursing care units are becoming increasingly specialized.24 It seems intuitive that a generalized approach to staffing is unlikely to be successful in the face of the trend toward specialization. Financial and Human Resources Essay Assignment

Nurse Satisfaction

In 2016, the NCU adjusted staffing to help adhere to ASPAN guidelines.22 Review of our nurse engagement and nurse satisfaction data, similar to Nadolski et al,4 demonstrated increased engagement and satisfaction. Mean scores increased for multiple items including RNs reporting that they have what they need, can make a contribution that gives meaning, have adequate staffing, and enjoy their job; all increased after the ratio change. It is well known that, when nursing staff are more satisfied with their job, they stay longer.25 This decreases turnover, staff stress, and cost of hiring new employees. Before the change in September 2017, our suggested nurse ratio was not aligned with the ASPAN standard, which gave room for improvement by increasing the number of nurses to patients. Before implementation of the new scheduling ratio, more nurses reported not being able to sit down during their entire shift, which can result in exhaustion and impair their ability to perform.26 According to Stalpers et al,27 nursing staff perception about the quality of care provided in the ICU has been identified to be independent of the way the same nursing staff feels about their personal job satisfaction.

Patient Satisfaction

Intensive care nurses play a vital role in building rapport with patients and their families. Nurses are not only care providers, but through maintaining close communication and spending more time at the patient’s bedside, they can better identify treatment-related concerns.28 Nurses with busier schedules and higher patient loads may be rushed to fulfill their responsibilities and hence have no time to review patient symptoms or respond to their concerns.29 It has been identified that heavy workloads hinder the capacity of nurses to thoroughly care for the patients and may impact patient satisfaction, nurse burnout, and even patient mortality.11,26 It seems likely that the lack of statistically significant differences in prescores and postscores in Table 2 reflects that Press Ganey may not be an appropriate metric for evaluating nurse-sensitive outcomes.30

Quality of Care

The greatest impact identified was decreased incidence of urinary tract infections (12 cases before the change vs 3 cases after the change). There was a decrease in ventilator-related infections (4:1) and pneumonia (1:0). Also identified were decreased cases of pressure ulcers (26:22) and complications of central line–related infections (1:0). Since the change, 6 falls were reported in contrast to 5 reported the previous year. Circumstances surrounding falls were investigated in detail, and it was identified that falls occurred on the shifts when staffing ratios were around 1 nurse for 2 patients (even higher than the RN:PT of 1:1.80 in 2016), which shows that there is improvement in many healthcare quality aspects among the ICU implementation contrary to the new adopted ratio of 1:1.73 to 1:1.63. Financial and Human Resources Essay Assignment

Limitations

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Change is not always easy to initiate, especially when there is a monetary impact on a unit or hospital. Nurses are constantly advocating for higher RN:PT ratios, but there are multiple barriers to creating this change. Overall, it was a lengthy process; the unit manager initiated conversations with upper level nursing and hospital administration in April 2017, and the staffing change occurred in September 2017. In addition, upper level management pushed to collect pre– and post–staffing change data for both the patients and the staff. This process involved a nurse scientist, a statistician, and a research coordinator. By integrating all of this infrastructure into the culture of change, the staff were able to visualize the impact of the staffing ratio change, which further motivated engagement, additional understanding of the metrics, and the outcomes of the metrics on the unit culture.This was a retrospective analysis that includes survey data and therefore is limited to the available data. Nurse census data were collected at 7 am and 7 pm; if a nurse came in at 11 am, they were not counted in the 7-am census. Changes to staffing ratios at various times throughout the day could be accounted for in future studies. In addition, the use of Press Ganey as a measure of patient satisfaction has limitations in that the responses are sometimes from patients who had to stay in our NCU overflow unit, which separated patient rooms by curtains and may impact patient satisfaction scores.30

Conclusion

The RN:PT ratio is an important metric that has implications for frontline management and upper administration. This study demonstrates the efficacy of using readily available data to examine nurse-sensitive outcomes and their association with staffing patterns. In this study, reducing the staffing ratio was associated with improved nurse satisfaction, decreased adverse events, and increased patient satisfaction. This study adds to the nursing literature that lower staffing ratios provide a cost benefit as well as demonstrate improved nursing-sensitive outcomes. Financial and Human Resources Essay Assignment