Nursing Sensitive indicators are guidelines that were implemented during the 1990’s when there was a need to restructure and evaluate nursing staffing and identify linkages between nursing to patient ratios and the patient outcomes. (ANA 1995.) I also believe that this redesign was also in response to the major nursing shortage of the 1990’s here in the United States. The American Nurses Association (ANA) implemented these guidelines in response. The American Nurses Association (ANA) describe nursing sensitive indicators “that reflect the structure, process and outcomes of nursing care. The structure of care is indicated by the supply of nursing staff, the level skill, and the education / certifications of nursing staff” (ANA, 2015).
Major deviations occurred during the course of Mr. J’s hospitalization. The patient is a Rabbi, and was given pork, the patient was given narcotics which further altered his mental status, leading him to increased risk of falls, therefore, requiring him to to be restrained, creating an increased risk of pneumonia and pressure ulcer by limiting his ability to change positions in bed, and forcing him to remain sedentary potentially causing fluids to pool in his lungs and adding to pressure on his sacrum.
Upon review of this scenario, the potential nursing sensitive indicators are would be to address all eight listed as the most commonly used indicators, but for this discussion, I will identify three.
Patient satisfaction: religious beliefs a blatant disregard for the patients religious practices. The patient was given a regular diet, and had eaten a pork cutlet, his daughter found out by accident. The patient may not be aware of the incident, but the daughter was certainly aware and called the hospital administrator indicating her dissatisfaction.
Complications as result of hospitalization: pressure ulcers; such as the reddened area noted by the patient’s daughter on the patients lower spine. The CNA disregards the reddened area, and doesn’t report it to the R.N., indicates a lack of understanding to the severity of the situation. With a pressure ulcer developing within the hospital setting, Medicare will not reimburse for the cost of the care of that ulcer. This affects the hospitals bottom-line, and most facilities have a protocol regarding any patients that come into a facility with a pressure ulcer pre-admission. To ensure that the care of the ulcer is covered by Medicare.
Length of patient hospital stay: The complication of the impending pressure ulcer on his lower spine, and use of restraints will lengthen the Rabbi’s hospital stay. The broken skin will be a weakened area where an infection could occur, that will make him more prone to acquiring a hospital nosocomial infection, further increasing his length of hospital stay. Further education needs to be provided to the CNA regarding the importance of the need to turn patients, and make sure that all pressure points are monitored to prevent skin breakdown. Evidence-based practice could be used to address the prevention of pressure ulcers, and use of restraints through bi-annual education for the staff on what signs to look for potential pressure ulcers.
Further education would also include: when, who, where and what is appropriate the use of restraints, requirements and laws pertaining to the use of them. Cultural practices and respect for one another is another example that should be addressed in this scenario. The nursing supervisor shouldn’t have ignored the dietary error and nor should he have told the staff to “Just keep it quiet. It will be okay.” The beside nurse should have been instructed to notify the family immediately, and have alternative safe guards in place to prevent this from occurring again. As a charge RN, I would have discussed this issue with the primary care nurse, and also discussed the importance of being sensitive to this issue. Another resource could also have been the primary care physician for whom was Jewish.
Hospital Data reflects that while insurance companies are paying less for care, shorter hospital stays for procedures that in the past required in-hospital stay. In order to stay competitive and make a profit. The hospitals are responding by targeting the largest group of employees in the hospital- The RN. As a result, they’re using cheaper licensed and non-licensed personnel: CNA, HA, and LVN’s creating higher patient to RN ratio, thereby increasing the patient acuity (Barter et al., 1994)
A 1997 ANA pilot study, described below, is an interesting study, describing the linkage between the use of RN’s and non RN’s. The ANA found that shorter lengths of stay are strongly related to higher RN staffing. The patient’s acuity was evaluated and adjusted on a daily basis, and the patient morbidity indicators for preventable conditions such as: pressure ulcers, pneumonia, postoperative infections, and urinary tract infections-are inversely related to RN skill mix. Indicating that the more RNs’ taking care of the patients, the fewer preventable conditions those patients experienced. Another study conducted in 1998, by Blegen, et al., found that a higher proportion of RNs was directly related to lower incidences of negative patient outcomes, such as medication errors, pressure ulcers, and complaints by patients and families.
It’s interesting to note, that while hospitals and health care facilities are aware of this evidence-based research, facilities need to become more aware of this data, and realize that having more RN’s make economic sense. And just looking at the immediate bottom lines, but to have some foresight on this phenomenon, and start collecting data at their own facilities.
http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSa fetyQuality/Research-Measurement/The-National-Database/Nursing-Sensitive-Indicators_1 Barter, Marjorie, McLaughlin, Frank E., and Thomas, Sue A. (1994). Use of Unlicensed Assistive Personnel by Hospitals. Nursing Economic$: 12 (2), 82-87. American Nurses Association (1997). Implementing Nursing’s Report Card. Washington, DC: ANA.
Blegen, Mary A. and Vaughn, Tom. (1998). A Multisite Study of Nurse Staffing and Patient Occurrences. Nursing Economic$: 16 (4), 196-203.
Blegen, Mary A., Goode, Colleen J., and Reed, Laura. (1998). Nurse Staffing and Patient Outcomes. Nursing Research: Jan./Feb. 47(1), 43-50.