Heart failure (HF) is characterized as an acute, progressive ailment that has been identified as one of the top concerns of patients and health-care systems in the United States (U.S.) (Travis et al., 2012). It has been discovered that over 670,000 instances of HF occur each year, with over 5.7 million US individuals suffering from the condition. As a result, heart failure has become one of the leading causes of hospitalization and death in the United States in recent years (Albert et al., 2009). Hospital readmissions at a relatively recurrent pace add more to the stress of patients as well as contribute to the society’s large expenses. Because of this, numerous HF clinics have been established for the past years for the purpose of improving care and treatment of HF patients. These HF clinics aimed to decrease mortality and morbidity rates as well as hospital readmissions. Moreover, HF clinics highly depend on competent and well-trained nurses to provide aid to HF patients in the state (Gustafsson et al., 2004).
This particular paper then aims to design an evidence-based resource or staffing plan for a heart failure clinic in Texas with the involvement of registered nurses (RNs). Certain elements and components shall be taken into consideration in the construction of this resource plan, which will be further discussed and analyzed.
The Texas Nursing Practice Act
The Nursing Practice Act (NPA) is fully described in Chapter 301 of the Texas Occupations Code (TOC). The NPA forms the Board of Nursing (BON) in Texas and describes its role in the standardization of nursing education, licensure and practice. According to the NPA, a professional license is required for any individual who will be working as a nurse in Texas. This license must be subject to renewal every two years for continuation of practice. The license enables the individual to hold the position of an “RN” or “LVN” and he or she must wear a name tag with these particular positions all the time especially when in a health care institution for identification purposes (Texas Board of Nursing, 2009).
The Nursing Resource or Staffing Plan
Importance to Patient Outcomes
Nurses have a big responsibility specifically in the health care system. Safe staffing ratios authorized by the state are highly important to guarantee the safety and security of both nurses and patients. In order to ensure an efficient patient care and nurse preservation, there should be sufficient staffing of nurses. Insufficient nurse staffing poses a threat to the career of nurses as well as to the care and treatment given to patients (DPE Research Department, 2016).
Research has constantly sustained the evidence that sufficient RN staffing can help promote positive patient outcomes, patient safety through reduced mortality as well as nurse satisfaction. Direct-care RNs have indeed a crucial role to play in terms of staffing and staffing processes (Mensik, 2014).
Staffing can be differentiated from scheduling. Staffing refers to the routinary process of operation in which there are individuals designated to perform a particular function in terms of evaluation and organization of shifting schedules. This is to guarantee sufficient staffing specifically in terms of nurses’ schedules and ratios. Shifts can range from 12 hours to 24 hours depending on the demand for immediate care and treatment in a hospital, clinic, unit or health organization. Scheduling, on the other hand, refers to the organization of a fixed number of staff or personnel for future needs based on patient volume and census data (Mensik, 2014).
Management Strategies and Best Practices
One of the best practices for an efficient nurse staffing plan is responsible professionalism on the part of nurses. It is their responsibility to be aware about effective staffing in the hospital, clinic or unit where they are working. Although it is the main role of nurse managers and hospital leaders to systematically organize nurse staffing, nurses should still be constantly up-to-date when it comes to staffing and scheduling (Mensik, 2014).
In terms of HF, two of the most important management strategies of nursing care for patients afflicted with this illness are proper education and counseling. This highly guarantees clinical stability and in turn, produces positive outcomes on the part of HF patients (Grady et al., 2000).
The main concentration of proper education is on pertinent information regarding HF as a disease and the processes related to it. Along with this, patients were also taught about the importance of regular monitoring of body weight, medical therapy, food and fluid intake limitations as well as the side effects of cardiovascular drugs. Nurses, together with physical therapists, also aid in physical therapy and training programs for quick recovery of patients who have undergone heart transplantation and other forms of surgery. Emotional and social support is also provided to elderly HF patients. Intensive follow-up of patients through home visits, phone calls or a mixture of these methods is also significant in reducing the mortality and morbidity rates of HF patients (Gustafsson et al., 2004).
Generally, a combination of professional skills, efficient organization and competent leadership among nurses produce a great impact with regard to patient outcomes. A nurse’s competence highly depends on the level of education, proficiency and experience that he or she has achieved. A higher level of education and nursing proficiency results to lower patient mortality and morbidity. The high quality of nurse performance greatly depends on the nurses’ competence and level of expertise in order to promote high standards of patient care (Kane et al., 2007).
There are some best practices and strategies specifically when dealing with nurse staffing ratios. In cases of failure and deficits in staffing, it is essential to hold a failure mode effect evaluation for the purpose of developing policies and alternatives to address insufficient staffing. The necessary adjustments should be applied in terms of census (number of nurses and patient volume). Effective communication and negotiation of strategies and options should be done to RNs as well as other healthcare personnel. Through proper training, RNs must be encouraged to determine appropriate solutions for staffing concerns. It would be best to conduct an annual survey in order to evaluate the safety and effectiveness of the staffing plan as part of nurse satisfaction. Moreover, RNs should also participate in decisions involving the healthcare institution annual budget. Staffing ratios should also be standardized yearly in relation to patient outcomes and other essential components. Appropriate information should be provided regarding hospital and patient quality outcomes in order to determine the needs of the staff. Patient satisfaction should also be assessed in relation to the efficiency of the nursing resource plan. Overall, the decisions of nurses should be taken into consideration in terms of staffing plans and ratios (Rich, 2009).
Effective Staffing
There are federal and state regulatory requirements with respect to ideal nurse staffing. In terms of federal requirements, hospitals with Medicare or Medicaid services should have a sufficient supply of licensed RNs, licensed vocational nurses and healthcare workers in order to effectively provide high-quality patient care. Failure to comply with such federal requirements results to penalties, which in turn contribute to additional health care unit costs (Mensik, 2014).
As for laws specific to Texas, certain nursing legislations in order to solve the issue of nurse staffing have been implemented. The state of Texas also requires hospitals to have nurse staffing committees for efficient planning of staff policies and guidelines. Texas also prohibits mandatory overtime among nurses (Rich, 2009).
In designing an evidence-based nursing resource plan, it is crucial to understand the importance of union contracts for RNs since this would highly affect the supply of RNs on a day-to-day basis. If RNs have signed or are working under a union contract, they are subject to settling arguments or going to a grievance process within the scope of the contract in order to object any disciplinary action related to the refusal of an unsafe nursing assignment. If RNs have not signed a union contract, they are required to take the necessary action in terms of grievance processes or peer reviews as well as seeking the help of lawyers (Congress on Nursing Practice and Economics, 2009).
Staffing levels are normally arranged by hospital administrators and are based on factors such as labor costs and scope of nursing practice. The decision of hospital administrators influence skill mix and features of the nurse staff, model of care utilized in the designation of staff members and the type of care and attention given as well as the environment where nurses work (Clarke & Donaldson, 2007).
Numerous components are to be considered when it comes to designing an evidence-based nursing resource or staffing plan. Among these components are: patient needs and demands, nurse expertise and experience, the prevailing culture and environment for nursing practice, and staffing policies and guidelines.
Patient needs and demands are to be addressed immediately and should be prioritized in terms of staffing decisions. Such needs involve the level of intensity, acuity or perception, complexity and stability of the patient’s health status and its associated procedures; the availability of social support as well as immediate care and attention even in outpatient settings; capacity to self-care; sudden hospital readmissions, patient turnovers or discharges; certain factors such as age, gender, status, background of previous ailments, linguistic diversity and communication skills which may affect the patient’s current conditions; and other profound needs determined by the patient, patient’s family, health specialist and the assigned RN (Avalere Health, 2015; Clarke and Donaldson, 2007).
Patient needs and demands provide the basis for accuracy in terms of nursing assignments and practice. Expertise and experience form a nurse’s credentials and qualifications. In order to ensure high standards of patient care and attention, an adequate supply of nurses who are licensed graduates or who have acquired professional certification should be given due importance. The level of professional experience in the clinical setting, community-based experience, expertise in terms of technological and clinical methods and techniques, effectiveness of communication skills as well as organizational experience are also taken into consideration when it comes to staffing decisions (Avalere Health, 2015). RNs should also be competent in terms of assessment, evaluation, diagnosis, organization, implementation, consultation, collaborative care, education of the patient’s health condition, outcomes determination as well as prescriptive treatment and influence (Mensik, 2014).
The prevailing culture and environment in the workplace also has an influential effect on the design of an ideal nurse staffing plan. Health care institutions should promote an environment that gives importance to nurses, regarding them as an asset and not a limitation to the institution or hospital system’s mission and vision. Aside from adequate staffing, a healthy workplace should include the following aspects: continuous skills training and improvement; efficient transport, clerical and laboratory services; adequate time for patient documentation; sufficient time to obtain increased patient documentation due to technological advancements; enough time for RN delegation and collaboration with other hospital personnel and staff members; procedures to aid during major alterations in the hospital setting; sufficient resources for educating patients and their families; sufficient support in terms of ethical decisions; and timely delegation, collaboration and negotiation in order to promote patient safety and accuracy in terms of outcomes data (Avalere Health, 2015; Clarke and Donaldson, 2007).
Finally, staffing policies and guidelines are highly significant in the design of an evidence-based staffing plan. Generally, there is no optimal model or set of guidelines appropriate for all types of health situations or settings. This is the reason why nurse staffing plans are specific to a certain ailment or to the status of the prevailing patient population. Nonetheless, certain elements should be taken into consideration in formulating staffing guidelines such as technology accessibility within the hospital, clinic or unit; architectural design or setup of the health care institution; development of intensive nursing care plans; quality measures and assessment tools; shared governance in the hospital setting; high standards of the workplace and assessment of practice outcomes involving safety and quality (Avalere Health, 2015; Mensik 2014; Clarke & Donaldson, 2007).
Delegation, Collaboration, and Negotiation
Delegation, collaboration and negotiation are three functions that are essential in the development of an ideal nursing resource or staffing plan.
In a nursing resource plan, it is important for the RN to properly assign the necessary actions to extend care and guidance to patients through accountability of their own actions. RNs have the responsibility to orient and supervise enrolled or inexperienced nurses, nurse assistants and unlicensed health care workers on what to do with regard to assigned patients (Nursing and Midwifery Board of Australia, 2006). Delegation is necessary since it takes into account the training and level of education of enrolled nurses, nurse assistants and other health care workers in terms of proper care and practice of clinical skills and techniques. It also entails efficient and timely supervision in order to guarantee that safe and accurate care is duly designated according to competence and area of expertise or practice (NSW, 2011).
Collaboration with HF specialists and with individuals working in health care organizations is also an important aspect of an RN’s role in the nursing staffing plan. The RN is responsible in the planning, implementation and evaluation of nursing care coupled with collaborative approaches. This is for the purpose of effectively targeting positive patient outcomes and efficiently dealing with health disparities related to gender, ethnicity, culture, age and other factors affecting patients. This will eventually result to accurate modification of nursing care practices in order to fit with the patients’ background information or data (Nursing and Midwifery Board of Australia, 2006; Al-Sawai, 2013).
Collaboration also entails coordination with an interdisciplinary health care team in order to provide appropriate and extensive nursing care to patients. RNs normally become team leaders in a hospital, clinic or unit through effective collaboration. It is a way in which two or more people work together in order to achieve the same goal. Addressing various issues and concerns in the hospital setting requires sharing one’s expertise, knowledge and training and this is deemed as collaborative effort on the part of RNs and their subordinates (NSW, 2011).
One of the goals of RNs is to ensure that they have the appropriate communication skills in order to effectively negotiate with patients as well as with related health care organizations (NSW, 2011). Effective communication skills are valuable in order to appropriately handle coordinated care in hospitals, clinics and specific units. It is through effective communication that RNs and their subordinates learn to negotiate or bargain properly in terms of assuming leadership in a team or accepting designated tasks as a team member (Al-Sawai, 2013).
Outpatient Services
An ideal nurse staffing plan deems outpatient services as a cost-efficient way of reducing hospital patient readmissions while maintaining high-quality patient care and attention. Nursing practice has been experiencing alterations from inpatient to outpatient settings for the past few years in order to reduce nurse fatigue and promote retention (Hughes, 2008).
In HF clinics, outpatient disease management programs are essential in the advancement of hospital outcomes. Nonetheless, little is known regarding the efficiency of nurse-managed population based managed care (PBMC) to enhance patient outcomes with regard to HF. Outpatient services in the case of HF clinics aim at decreasing mortality and patient readmission rates while being geared towards the improvement of the patients’ quality of life. This is done by means of an in-depth individualized care and attention given to HF patients (Travis et al., 2012).
Cost-Effectiveness
An effective nurse staffing plan should be geared towards the improvement of patient outcomes. An ideal nurse staffing plan is characterized by adequate staffing coupled with high-quality, cost-efficient patient care and treatment. Adequate staffing leads to clinical, economic and social enhancements in terms of patient care and satisfaction. It also results in decrease of mortality, morbidity, duration of stay, occurrence of healthcare-related infections, possible accidents such as falls, and costs associated with frequent or unprecedented hospital readmissions among patients. Nurses also benefit from adequate staffing since there is also reduction of nurse fatigue which results to better nurse retention, satisfaction and safety (Avalere Health, 2015).
Nurses are regarded as one of the major contributors to about 40% of the operation costs in hospitals. A decrease in the labor costs of nurses may be deemed as an appropriate solution in order to address the issue of overhead costs, yet it can cause drawbacks in terms of patient care and hospital quality (Avalere Health, 2015). Nonetheless, costs may be controlled through the reduction of overtime occurrences among nurses. A limited number of nurses who are made to go on overtime shifts contribute to the overhead expenses in hospitals and clinics. Around 63% of hospital expenses come from nursing labor costs or salaries due to overtime. Thus, overtime occurrences result from insufficiently planned nurse staffing (Tierney, 2010).
Cost-efficiency is associated with nursing intensity, which is a parameter used to determine nursing unit staffing. This is viewed by means of hours per patient day (HPPD), and the optimum HPPD to ensure adequate staffing according to the National League of Nursing Education (NLNE) is 3.5 HPPD. In this case, the patient to nurse (PTN) ratio should be estimated to at least 7:1. In the assessment of nursing workload, nursing quality, hospital quality and patient safety outcomes, HPPD, PTN and skill mix are considered as crucial parameters, and these are also factors considered in an ideal staff plan (Tierney, 2010).
The cost-efficiency of a nursing staff plan thus relies on the adequacy of the nursing staff in order to guarantee high standards of care and attention given to patients, thereby controlling costs through decreased patient readmissions and regulation of hospital revenue. Outpatient services are also deemed as cost-effective (Avalere Health, 2015).
Conclusion
An important component in an evidence-based nursing resource plan is adequate nurse staffing since it promotes reduction in patient mortality and positive patient and hospital outcomes. Cost-efficiency is also deemed essential in an ideal nursing plan and this is achieved through a PTN of at least 7:1 with no mandatory overtime in order to promote nurse retention and reduced hospital readmissions while at the same time, obtaining high-quality patient care and attention. Outpatient services also contribute to the cost-efficiency and optimum condition of an institution such as the HF clinic. Other components such as patient needs and demands, nurse competence, workplace status and staffing guidelines are also essential in the design of an ideal nurse staffing plan.
A nurse staffing plan specifically designed for an HF clinic in Texas is shown in Appendix A. It involves all the necessary techniques, methods and guidelines to address the concerns of HF patients along with a sample schedule for nurse staffing.
It is recommended in future studies that the impact of various staffing models be investigated and analyzed specifically for HF clinics.
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Appendix A
Sample Nursing Staffing Plan (Table 1) for a Texas Heart Failure Clinic
Patient Population
Acuity Levels
Unit and Care Intensity
Environmental Setup and Related Factors
Patients recently hospitalized for Heart Failure-45%
Acuity or perception levels differ by service and diagnosis. Acuity strategies have been carried out but currently the General Practitioner and the Specialist Heart Failure (HF) nurse handle the perception level daily to maintain safe nurse to patient ratios
Out of a total of 20 beds, 8 patients are admitted for HF. Admission rate is 40%. We have a variety of post-surgical patients and cardiac/HF patients. Patients spend several days to weeks in the clinic especially after intensive treatment or surgery. All RNs of an HF clinic are required to have ACLS certification.
10 private patient rooms equipped with cardio-monitoring devices.
1 Emergency Room
1 Surgery Room
1 Recovery Room
2 rooms for HF consultation (outpatients).
1 medication and supply room
1 room for research and heart transplant evaluation
1 utility room
1 nutrition and physical therapy room
All rooms may accommodate 1 overnight guest only.
One RN per station
Family lounge available at the clinic lobby.
Rooms have bar code scanning and vital signs integration devices.
High Risk Patients afflicted with:
Renal insufficiency
Diabetes
COPD
= 25%
The aim of an HF clinic is to provide the necessary medical follow-ups, appropriate medical treatment, and therapy especially to Class III and IV HF patients.
Retained symptoms of NYHA Class III and IV- 10%
HF patients shall be educated as well with information about the disease, policies for proper food and fluid intake and the use of medication (side effects and purpose)
Elderly patients and other patients with multiple complications- 15%
Tips shall also be given regarding proper lifestyle and handling of HF through adequate exercise, monitoring of daily weight, proper nutrition and eating, as well as appropriate handling of stress and stress-related factors
Patients with strong history of depression or mental impairment with no application of any form of therapy- 5%
Other services of the HF clinic include:
-Evaluation of heart transplants
-Research programs
-Surgery
-Pallative Care
-Home Care (especially for those undergoing diuretic therapy)
Also included are:
ST- and Non ST- elevation myocardial infarction patients admitted before to the CCU who show12-24 hours of stable vital signs (such as the absence of heart failure symptoms)
Sample Nursing Staffing Plan (Table 1- continuation) for a Texas Heart Failure Clinic
Essential Staffing
Nurse Staffing Schedule
Measurement Methods
The Systematic Network of an HF clinic includes the ff:
General Practitioner
Specialized HF nurse
Registered nurses (RNs)
Cardiologist/ HF specialist
Elderly care (Geriatrician)
Dietitian/Nutritionist
Pharmacist
HF Rehabilitation
Volunteer workers
Social service workers
Possible Shifts:
9 AM- 6 PM
6 PM- 3 AM
3 AM- 12 PM
12 PM- 9 PM
*The 3 AM-12 PM shift is optional especially if there are confined HF patients. Nonetheless, the regular shifts are 9 AM- 6 PM and 6 PM to 3 AM only. At least 1-2 RNs are assigned per shift if the patient volume is less than 10 but if it reaches 10-20, there should be at least 3-4 RNs on duty to optimize patient care and attention
* Mandatory overtime is not necessary in this case.
Non-clinical methods:
Staff turnover
Patient turnover
Use of sick leave (staff)
PTN of at least 5:1 is to be achieved (4 nurses on shift to handle at least 15-20 patients); If the patient volume is less than 10, there should be at least 1 or 2 RNs per shift; Nurse rotation is on an 8-12 hour basis depending on patient volume
*The specialized HF nurse can work on a 6 to 8-hour shift only since they are responsible in making rounds and task delegation
Clinical Methods:
-Patient/Chart audits
-Monitoring incidence of patient falls (if necessary)
-Monitoring of heart transplants and heart transplant referral candidates
-Monitoring of patient admissions, readmissions, transfers and discharges
-Proper education (medication therapy, nutrition, fluid intake, importance of exercise, importance of self-care)
- Telephone follow-ups and home visits
-Administering of HF-specific medications or treatments (ACE-inhibitors, beta blockers, implantable cardiac defibrillator)
In a nurse-directed HF clinic, the specialized HF nurse is responsible for delegating tasks to the RNs and in collaborating with the general practitioner and other clinic personnel; collaboration with other departments or health care units (i.e. cardiology units) is important in order to specifically address admissions and readmissions, transfers or discharges
