Changing Staffing Patterns and Reducing Healthcare Costs

¶ … Mandatory Overtime Policies

Organizational Culture and Readiness Assessment

The results of the Organizational Culture and Readiness for System-Wide Integration of Evidence-Based Practice checklist, which summarizes the survey results, are discussed with regard to the readiness level of the organization, possible project barriers and facilitators, and plans for integrating with clinical inquiry.

The overarching characteristic of the state of readiness of this organization for system-wide integration of evidence-based practice is moderately encouraging, while still indicative of some concern regarding barriers to implementation success. The stakeholders in the organization are aware of the importance of evidence-based practice and they are fundamentally supportive. The organization provides resources to support the integration of evidence-based practice into the institution, however, the availability of skilled staff who can assist with the changes is limited (Battilana & Casciaro, 2012). Two related and high scoring items in the survey have to do with the availability of quality computers and electronic databases for nursing staff to search evidence-based research and the extent to which staff nurses are proficient in computer skills. Also high scoring items are responses to the questions about the extent of the knowledge and skills librarians have about evidence-based practice, and the extent to which librarians are used to search for evidence. And while the extent that advanced practice nurses are available to be mentors for staff regarding evidence-based practice, the survey respondents indicated that there is not a critical mass of nurses who have strong evidence-based practice knowledge & skills nor are there sufficient nurse researchers with doctoral level preparation available to assist in the generation of evidence (Battilana & Casciaro, 2012).

Battilana and Casciaro (2012) explored the impact that the type of organizational change has on the ability of change agents to introduce a new practice in an organization. The contingency theory of organizational change and the structure of networks are supported by the Battilana and Casciaro (2012). Interestingly, when there are breaks or holes in the networks of those who influence change, there seems to be a willingness to initiate bolder organizational change. Moreover, those gaps in the network appear to hinder the adoption of changes that are more similar to the status quo (Battilana and Casciaro, 2012). What this can mean to the use of resources within the organization is that perhaps the divergence across the stakeholders may support a bolder change initiative. Knowing this counter-intuitive finding from Battilana and Casciaro (2012) is a step toward integrating clinical inquiry into the organization, providing strategies that strengthen the organizations weaker areas.

Section B: Problem Description

Background

The practice of mandatory overtime is an issue for the workplace and for patient safety. The literature defines mandatory overtime as, "the practice of hospitals and health care institutions to maintain adequate numbers of staff nurses through forced overtime, usually with a total of twelve to sixteen hours worked, with as little as one hour's notice" ("AACN," 2001). Mandatory overtime is a regular practice and not one implemented in order to address unforeseen emergency situations. Accordingly, mandatory overtime policy does not permit nurses to refuse the additional required hours due to fatigue or out of concern for patient care ("AACN," 2001). Moreover, time that is identified as "on call" is not included in this mandatory overtime requirement unless it falls immediately before or after a scheduled shift and would cause a double shift situation ("AACN," 2001).

Stakeholders

The stakeholders who are involved in the mandatory overtime situation and the issues that result from its implementation include the following: Administrators, advanced practice nurses (APN), nursing staff, nurses with doctoral preparation and librarians to help with evidence-based practice inquiry, patients, and physicians.

PICOT

The theory driving this PICOT is that disallowing mandatory overtime in a hospital or health care institution will result in higher quality patient care, greater job satisfaction by nursing staff, and improvements in institutional reputations, which will translate into greater return on investment (ROI) (Bae, 2010, 2013). Understaffed hospitals are expected to explore strategies that directly and indirectly address the presumed need for mandatory overtime, such as determining how to recruit, hire, and retain more nurses (Trinkoff, et al., 2003). The ANA study, Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting (3/2000), tracks and reports on five adverse outcomes measures that are associated with staffing. When the patient to nurse staffing ratio is appropriate, the following outcomes can be mitigated: "Length of hospital stay, nosocomial pneumonia, postoperative infections, pressure ulcers, and nosocomial urinary tract infections" ("ANA," 2006).

The therapy / prevention PICOT is based on the belief that sufficient nurse staffing will result in more time being available for more thorough patient assessment and more thoughtful and timely interventions that will improve patient outcomes. The acronym PICOT represents the following concepts:

P = Population / Patient Problem

I = Intervention

C = Comparison

O = Outcome

T = Time

The PICOT states, "Does (P) the quality of patient care improve in hospital units that (I) disallow mandatory overtime versus ( C) hospital units that implement mandatory overtime policies as measured by the ANA indicators (T) during the six-month period following the interventions?" The objective is to determine the change in indicators and multiple measurements will be taken in order to capture change.

Section C: Literature Support

Databases

This paper reviews the relevant literature of mandatory overtime for nursing staff in hospitals and health care facilities. A comprehensive electronic search was conducted using the following resources:

CINAHL

Cochrane Systematic Reviews

Joanna Briggs Systematic Reviews

EBSCO Host

National Academies Press

National Guideline Clearinghouse

Ovid

PubMed

English-only, peer-reviewed publications from 1976 through 2014 were included in the search. Search key words included: mandatory overtime, nursing staff overtime, patient safety, nursing job satisfaction, nurse fatigue, cost-saving in hospitals, recruiting nurses, hiring nurses, and hidden costs of mandatory overtime in hospitals. Articles from nursing, hospital administration, institutional and professional change management, and healthcare policy were included. Articles with an evidence level of II and below were fully reviewed. This discussion presents the major findings from the reviewed literature, and the reader is invited to refer to Appendix D and E. For more information.

Literature Review and Synthesis

Studies unequivocally support the disallowance of mandatory overtime for nursing staff. Numerous studies have concluded that when direct care medical employees work for longer than 12 hours during a single shift, their fatigue levels escalate and the likelihood increases that they will make an error ("ANA," 2000; Kohn, 2000; Nui, et al., 2013; Scott, et al., 2006). Scott, et al. (2006) conducted as study in which nurses completed logbooks to note any relevant information or conditions regarding their work schedules, levels of alertness and fatigue, and errors in practice or decision making. The study found that 502 nurses consistently worked for extended periods of time and longer than scheduled. Moreover, the risk of errors and near errors increased with longer work durations, and the vigilance of nurses decreased accordingly (Scott, et al., 2006). These findings support the recommendations made by the Institute of Medicine (IOM) to reduce the occurrence of 12-hour shifts and to limit consecutive work hour to no more than 12 out of every 24-hour period ((Kohn, et al., 2000; Scott, et al., 2006). An Institute of Medicine (IOM) report on medication errors provided data that substantiates this conclusion (Kohn, et al., 2000). Moreover, the experts who compiled the IOM report findings made specific recommendations for staffing configurations that would prohibit mandatory overtime as a driver of medication errors and limit known unsafe practices (Kohn, et al., 2000).

Niu, et al. (2013) Nui, et al. (2013) conducted prospective, randomized parallel group trials to explore the effect of sleep deficits on selective attention and the ability of nurses on different shifts in a medical center in Taiwan to perform their duties. The researchers concluded that sleep deficit affect neurobehavioral functioning, reduce attention and cognitive function, and negatively impact occupational safety (Nui, et al., 2013). Significant differences in selective attention indicators were observed between the fixed-day-shift group, which served as the control group, and rotating-shift group, which was the experimental group (Nui, et al., 2013). The error rate on night shift for the experimental group was 0.44 times more than that on day shift and .62 times more than on evening shift (Nui, et al., 2013). Nurses working the night shift demonstrated poorer speed and accuracy on attention-based performance tests than did the staff on day shifts. Since inadequate sleep and a state of somnolence was shown to adversely affect the attention and functioning speed of night-shift workers, the researchers recommended that more than two days off be provided when nurses must transition from the night shift to other shifts; this recommendation is intended to provide adequate time for the adjustment of circadian rhythms (Nui, et al., 2013).

Section D: Solution Description

This section provides a discussion related to the evidence-based practice project solution.

Proposed Solution

Mandatory overtime places nurses and their patients at increased risk of medical errors. At the very least, nurses should be able to decline overtime work on the basis of their assessment of their capacity to provide effective and safe care for patients at the time the request for overtime is communicated to them. The refusal of overtime assignments must not be associated with any derogatory performance evaluation or deemed an uncooperative and non-professional attitude. Moreover, legislation that governs overtime work for medical staff has been drafted and needs to be moved out of committee and enacted into law. In conjunction with this proposed legislative action, medical associations shall continue to provide education to the public and to administrative staff and governing boards on the negative impact of mandatory overtime on patient safety, on institutional liability, and on the job satisfaction of nurses.

One of the major considerations when evaluating the feasibility of the intervention is the status of the overall commitment of the hospital administration and relevant stakeholders to addressing the grand scheme of costs within the healthcare institution. Examples of highly effective cost reduction schemes are presented and reviewed in the literature, but they are all voluntarily undertaken and require a relentless pursuit of excellence in administration and operations with regard to costs, patient care and safety, and job satisfaction. The extent to which the proposed intervention may be considered feasible or not rests squarely on the motivation, skills, and knowledge of key stakeholders.

The proposed solution requires action by hospital administrators and other relevant stakeholders to mitigate the effects of overwork and fatigue caused by mandatory overtime of nursing staff. A three-pronged approach is recommended: 1) Permit nursing staff to decline to work overtime based on self-assessment of fatigue levels and concern for patient safety (Scott, et al., 2006); 2) shifts be limited to a maximum of 12 consecutive hours, and that this configuration be considered sub-optimal and not standard (Kohn, et al., 2000); and 3) that an absolute minimum of two non-work days be required between shifts that require a transition across day, night, and graveyard schedules (Nui, et al., 2013).

Organization Culture

Organizational readiness variables indicate that the culture strongly supports the idea of evidence-based practice, which in the proposed solution, entails modifications of staffing configurations to eliminate mandatory staffing in the experimental group. This solution is consistent with the organizational culture and with the professional goals of the nursing staff and hospital administration. Moreover, model hospital programs have demonstrated that healthcare institutions can effectively reduce costs across the units in a manner that enables safe and effective patient care and appropriate, balanced expectations for nursing staff.

Expected Outcomes

The outcomes that are expected to be generated from the proposed practice solution include reductions in the five following measures for patients: Length of hospital stay, nosocomial pneumonia, postoperative infections, pressure ulcers, and nosocomial urinary tract infections" ("ANA," 2006). In addition, nurses will be surveyed to ascertain their perceptions regarding improved confidence in the ability to provide safe, high quality patient care, job satisfaction, and personal well-being.

Method to Achieve Outcomes

Hospitals in Maryland state have collectively reduced Medicare costs by more than $!00 million dollars in one year, and have been granted a waiver to the Medicare billing process that ties reimbursement to admission (Walker, 2014). The savings are dramatic and the model is comprehensive, demonstrating the capacity of medical institutions to reduce costs without reducing the quality of patient care (Walker, 2014). Oversight of the model includes several substantive stakeholders, including the U.S. Centers for Medicare and Medicaid Services, Maryland Citizens Health Initiative, the Maryland Hospital Association, and the Maryland Health Services Cost Review Commission (Walker, 2014). The initiative addressed both clinical and nonclinical barriers to cutting costs, and had to demonstrate the ability to foster preventative care while cutting costs (Walker, 2014). The Maryland hospital initiative is a clear demonstration that patient care quality can be maintained while costs are simultaneously reduced (Walker, 2014).

Outcome Impact

The model employed to achieve the desired outcomes is designed to positively impact the following indicators: Quality care improvement, patient-centered quality care, efficiency of processes, and environmental changes. The Stetler (2001; 2010) evidence-based change model coupled with the adopted framework of the Maryland Hospital Association for Medicare cost reduction will generate deep institutional change that will be felt in all or nearly all units of the hospital.

Section E: Change Model

The current proposal utilizes the Stetler model that links evidence-based research to implementation in informed practice (see Appendix V -- Conceptual Model). The use of research in practice occurs in three ways: 1) Instrumental use, 2) conceptual use, and 3) symbolic (political / strategic) use (Stetler, 2001). Instrumental use is the direct application of knowledge gained through research (Stetler, 2001). Conceptual use is demonstrated when the understanding and perceptions about the way an issue is considered changes as a result of exposure and learning from research findings (Stetler, 2001). Symbolic or political / strategic use is observed when research is used to justify a decision or policy, and to influence the behavior and thinking of individuals (Stetler, 2001). Importantly, the Stetler model of research use incorporates the idea that internal attributes of individual users and variables in the external environment both influence how and the extent to which research knowledge is used (Stetler, 2001).