Quality Improvement Intervention and Proposal

Quality Improvement Intervention and Proposal

Introduction

Nurses fill a vital and irreplaceable role in the provision of health care to patients. However, currently, the nation is experiencing a shortage of registered nurses, and health care facilities are forced to operate with few registered nurses on staff. Moreover, forecasts indicate that the need for nurses will only grow as the Baby Boomer generation ages out of the workforce and increasingly needs medical care. The omission of care is a potentially lethal phenomenon for patients, and it lowers the overall quality of care offered by the health care facility. Before a sufficient number of registered nurses can graduate to fill the gap being currently experienced, solutions have to be found as a stopgap. One such solution that numerous facilities have implemented is to fill the registered nurse positions with support workers, such as nursing aides. Given this situation, the question to ask then is in health care facilities that have too few registered nurses, how does the use of support workers performing registered nurse duties compare to not having support workers influence the quality of care given as measured by the rates of omission of care over one year.

Problem Statement

The shortage of nursing staff is a problem that has been increasing in severity in recent years. Indications show that it will keep on increasing in the medium-term. According to the Bureau of Labor Statistics (2019), registered nursing is one of the fastest-growing occupations, and will remain so until 2026. The Bureau’s forecasts indicate that the number of registered nurses will grow by 15% in the ten years between 2016 and 2026. In addition to this growth, about 200,000 new registered nurses will be needed as health care facilities expand and older nurses retire (Bureau of Labor Statistics, 2019). Other estimates indicate that by 2030, about 1 million nurses (approximately 33%) will have retired, and if that number is not replenished, the provision of health care will suffer for years (Buerhaus, Skinner, Auerbach, & Staiger, 2017). Various institutions have called for an increase in the number of nurses. The Institute of Medicine (2011), for example, has called for an increase in baccalaureate-prepared or doctoral nurses to 80% of all nursing staff, but as of 2010, the figure was only at 56%. From these figures, it is evident that the shortfall of registered nurses will not end soon.

The nursing shortage has several causes. One of the greater problems is that enrollment in nursing schools is not rising fast enough to meet the increased demand for services. In 2018, enrollment increased by only 3.7%, which is far short of the ideal target (Zhang, Tai, Pforsich, & Lin, 2018). The enrolment shortage is affecting not only primary care providers but researchers and nursing school faculty. The shortage in faculty is partly responsible for depressed enrollment numbers. Besides, over half of nurses are nearing retirement age. As of 2018, 50.9% of nurses were over the age of 50, meaning that in the next decade, half of all nurses will have retired (American Association of Colleges of Nursing, 2019). Moreover, the nation’s demographics are changing, and the number of elderly people who typically require more nursing care will increase.

As a solution to this problem, numerous health care facilities are engaging the services of support workers in an attempt to fill the personnel shortfall. However, such support and personal care workers are less trained and have fewer certifications than baccalaureate-prepared and doctoral nurses (American Association of Colleges of Nursing, 2019). Also, such aides are legally restricted from performing some of the duties that a registered nurse would perform. However, the problem of the nursing staff shortage is a long term one, which will only be fully alleviated by increasing the number of graduating nurses. Therefore, it is vital to determine whether the use of nursing support workers is actually beneficial to the quality of care provided or whether it is simply a waste of resources.

Literature Review

Duffield, Roche, Twigg, Williams, and Clarke (2016) assess the impact of adding support workers to alleviate nursing shortages. The authors note that increased workloads caused by nursing shortages compromise the ability of nurses to provide quality care that meets the needs of patients. However, Duffield et al. (2016) note that filling vacant positions with support workers dilutes the skill mix of the professionals reduces job satisfaction by registered nurses and results in negative outcomes for patients. Instead of this substitution method, these authors advocate for introducing support workers as additional staff. The authors note that the increased workload experienced by licensed nurses reduces the quality of patient care and cause adverse patient outcomes by limiting the time for patient contact and performing critical tasks such as administration of pain relief. Therefore, the addition of support workers will result in the delegation of tasks, particularly non-clinical responsibilities, such as admission and patient hygiene. This move will increase the time spent by registered nurses in direct care activities, for instance, assessment and clinical procedures. Thus, introducing support workers will reduce nurses’ workload and increase contact with patients. Additionally, increased workloads result in job dissatisfaction among nurses, which leads to high job turnovers. Hence, adding support workers will spread the workload, and as a result, increase job satisfaction. However, the authors contend that the need for continuous supervision of nursing support workers might lessen this advantage. Nonetheless, Duffield et al. (2016) conclude that the addition of nursing support workers will result in improved patient and nursing outcomes due to increased patient contact by registered nurses and high levels of job satisfaction.

Duffield et al. (2018) explore the impact of incorporating support workers as part of the staff in acute hospitals. The idea is seen as a way of reducing nursing workload, addressing shortages, and improving patient outcomes. However, the analysis did not support this position. The authors noted that in most cases, the addition of support workers was used as a substitution method rather than a complementary one, which lowered the skill-mix in the majority of the investigated cases. The authors also did not find any notable variance regarding the perceived quality of emotional care provided to patients in wards with support workers when compared to those that only relied on qualified practitioners. The finding was counterintuitive to the presumption that adding support workers would increase the capacity to conduct all care activities in a timely fashion. The authors opined that this observation indicated that support workers were mostly added using a substitution method. In fact, the wards without support workers demonstrated an increase in the quality of care when compared to those that had employed them. Factors that were found to have a significant impact on the quality of care were nursing leadership, staffing of registered nurses, available resources, and nurse experience. Therefore, a simple approach, such as adding support workers to a ward could not lead to notable improvements in the quality of care.

Griffiths, Ball, Murrells, Jones, and Rafferty (2016) examined the relationship between mortality rates in different hospitals with registered nurse staffing while taking into consideration health care support worker staffing. The differences in-hospital mortality rates motivated the research despite the introduction of policies that focus on improving patient safety and increase of hospital budgets. The authors noted that the rise in the number of registered nurses was associated with low mortality rates. This finding has informed policies regarding the number of minimum nurse-patient ratios in many states in the US and Australia. However, in both hospitals with a high number of nursing support workers and a high proportion of support workers when compared to registered nurses, the mortality rate was higher. Essentially, filling vacant nursing positions with more support workers had an adverse effect on patient safety, which is demonstrated by the increased mortality rates. Therefore, the authors opined that although support workers may be relied upon to deliver essential care, their absorption into a hospital staff could not substitute the role played by licensed nurses in ensuring patient safety.

Similarly, Ball (2017) examines the association between the use of support workers and the high risk of death experienced in acute hospitals. The author contends that when registered nurses face an increased workload, the caregivers are likely to fail in administering some nursing care to particular patients. Through the use of surveys and observational design to collect and analyze data, Ball (2017) established that the increase in the number of registered nurses resulted in a lower risk of mortality for patients. However, little evidence was found to determine the impact of support workers on patient safety. The author noted that the research revealed no difference in the introduction of nursing support workers and the mortality rates of the patients. Ball (2017) also determined that the increase in the number of support workers had a direct correlation to poorer outcomes among surgical patients. Hence, support workers played a small role in ensuring patient safety. Therefore, increasing the number of support workers does not necessarily improve patient safety when little attention is paid to the number of registered nurses.

Ball, Murrells, Rafferty, Morrow, and Griffiths (2013) examine the relationship between missed care episodes and nurse staffing levels. The authors note that many research works have demonstrated that lower nurse staffing levels have an adverse impact on patient outcomes. Importantly, the authors also explored the relationship between support workers and registered nurses to determine the former’s impact on the quality of care. Interestingly, Ball et al. (2013) discovered that support workers were not found to have any impact on either the amount of missed care or their functions that were reported by registered nurses. Essentially, while support workers deployment was viewed as a means of improving the efficiency of care delivery, they were not associated with the cases of missed care among the nursing tasks that were studied. Notably, the examined responsibilities were those that were generally regarded to be handled by registered nurses, which would explain the failure to notice whether the support staff were working as substitutes or complements. Consequently, the authors asserted that the presence of support workers did not increase the ability of registered nurses to handle the examined tasks. Thus, the authors demonstrated that the use of support workers does not improve the quality of care in hospitals due to the complexity of the majority of tasks handled by registered nurses.

Roche, Friedman, Duffield, Twigg, and Cook (2017) investigated the roles played by nursing support workers and the impact on the care provided by licensed nurses. The authors acknowledged that the global nursing shortage has forced many hospitals to introduce unregulated nursing support workers to reduce the burden on the existing staff. However, little information exists on the roles filled by these support workers and the impact on registered nurses. Roche et al. (2017) used logistic regression models to compare whether support workers and registered nurses conducted direct and indirect patient care tasks and whether the latter were more likely to perform these roles in units with nursing support workers when compared to those without. The authors noted that nursing support workers handled most of the direct care tasks, such as admission and assessment. Additionally, registered nurses in units with support workers were found to undertake more tasks related to direct care when compared to units without support workers. Therefore, the authors opined that the introduction of support workers would result in potential duplication of tasks without proper delegation. As such, support workers did not necessarily ease the burden on registered nurses. The authors concluded that although nursing support workers are a viable solution for wards where a high level of direct care is required, their impact is limited by the model of care implemented, which determines the effectiveness of their integration and delegation of duties.

Sarre et al. (2018) focus on the training, support, and assessment of support workers within the healthcare industry and the challenges they face that affect their impact. The authors realized that while support workers received induction training, the preparation did not fully prepare them for what they would face in the wards. Gaps were also identified in training, particularly caring for patients with cognitive impairment, handling challenging conversations, and managing the emotions of patients, their relatives, and themselves. The lack of proper training was attributed to the urgency to reduce nursing workloads resulting in little time spent in training, the negative attitudes of ward managers on the importance of support workers, and infrequent provision. The authors also noted variances in the supervision and assessment of a support worker’s competencies in the three hospitals that were investigated. Consequently, while many hospitals are employing support workers to supplement the work done by nurses, the lack of effective training has limited their impact on the quality of care. Therefore, Sarre et al. (2018) concluded that the use of support workers does not necessarily result in improved quality of care due to the poor training methods that are not sufficient to prepare them for the realities in the wards.

Wilberforce et al. (2017) examined the role played by support workers in community mental health teams among older adults. While recognizing that the support workers provide essential help to the elderly who demonstrate complex physical and mental needs, the authors note that the lack of clear boundaries with qualified practitioners combined with a lack of support reduces their ability to improve quality care. Thus, although support workers understood some tasks were beyond their competencies, the authors found evidence of negotiated boundaries that breached their scope. This group of workers also experienced considerable autonomy over their duties, although they needed to work under supervision. Additionally, the training programs for support workers were insufficient and challenging besides failing to provide the group with the proper foundation to prepare them for a hospital setting. The low pay and time pressure also created barriers for those who sort to seek formal qualifications. Based on these findings, the authors noted that the roles of support workers seemed to substitute rather than complement that of qualified practitioners. Therefore, the lack of support, supervision, clear boundaries and appropriate training reduced the impact of support workers on the quality of care.

Koy, Yunibhand, Angsuroch, and Fisher (2015) investigated the relationship between nurse staffing, employee motivation, the hospital environment, stress and fatigue, and the nursing care quality. The authors noted that the quality of care was defined by the ability to meet the needs of the patients, which were either physical or psychosocial. Poor nursing care was reported in hospitals, which was as a result of unbalanced shift lengths and poor scheduling characteristics. Additionally, increased workloads arising from shortages of nurses also resulted in high job dissatisfaction, which not only increased the staff turnover but also reduced productivity and proper care. Thus, most hospitals resorted to adding support workers in addressing this problem. However, the authors noted that this intervention was only successful when the hospitals maintained an appropriate proportion or registered nurses compared to support workers. Similar to other researchers, the authors noted that when support workers are added using a substitution method, the quality of care in the health facilities declined due to low skill mix. Therefore, the addition of support workers failed to replace the training and experience of nursing staff when used to fill vacant positions. However, when the support workers are added to complement the existing staff, the authors noted that they could reduce the impact of burnout, which will improve job satisfaction and reduce employee turnover of nurses. Consequently, support workers can only enhance the quality of care in a hospital when they are added in a complementary role rather than when they are used to fill vacant positions.

Summary of Findings

Although support workers help to reduce the workload of registered nurses, which increases the latter’s job satisfaction and motivation, their impact on the quality of care is limited. When support workers are allocated duties that should be handled by registered nurses, the quality of care reduces since they lack the proper knowledge and expertise associated with the latter. In fact, their addition results in the dilution of the skill mix in a ward, which results in poor services. Additionally, they require constant supervision when handling registered nurse duties, which is counterintuitive to the presumption that their employment will provide registered nurses with more time with patients. Support workers are only beneficial if they are granted non-clinical duties, such as admission and patient hygiene, rather than performing registered nurse duties. In such a structure, the registered nurses will have more time to attend to patient needs. However, the proposed method looks at using support workers to perform registered nurse duties, which will cause negative patient outcomes. As reiterated by Duffield et al. (2018), hospitals without support workers performing registered nurse duties will record a higher quality of care when compared to those that hire them. Indeed, Griffith et al. (2016) noted an increase in mortality rate in hospitals that used support workers compared to those that did not hire any. Therefore, in hospitals that have too few registered nurses, the use of support workers to perform registered nurse duties lowers the quality of care provided and increases negative patient outcomes.

Implementation and Evaluation Plan

Although nurses play a critical role in healthcare, there is a chronic shortage of these essential workers in the country, with many institutions being understaffed. According to the American Association of Colleges of Nursing (2019), the problem is further exacerbated by the fact that 50% of nurses were aged 50 years and above as of 2018, indicating that they will retire in a decade. On the other hand, the enrolment in nursing schools, which only increased by 3.7% in 2018, is not rising fast enough to meet the rising demand (Zhang et al., 2018). Therefore, hiring nurse assistants can help care organizations to address the problem of nursing shortages, albeit temporarily. The solution is necessary as a means of freeing up more time for nurses to focus on patient care. After all, the shortages increase the chances of missed nursing care, which adversely affects patients’ safety. While hospitals may not be able to hire more nurses immediately, they can implement a temporary solution of employing nurse support staff to assist the nurses in carrying out critical medical services.

Intervention Plan

Having outlined the problem, the hospital should hire nurse assistants to support non-clinical tasks. The priority should be given to those professionals who are qualified as certified nurse assistants (CNAs). The hospital should also encourage those CNAs enrolled in nursing school to apply for the positions. When hired, the scope of responsibility of the nurse aides should be limited to helping patients with activities of daily living, which they are to perform under the supervision of a registered nurse (RN) or a licensed practical nurse (LPN). One of the essential qualities that CNAs must possess is an attitude that supports patient safety. Those who will do the screening must thus assess each potential CNAs attitude towards the subject to ensure that only those who are committed to enhancing patient safety are hired.  Overall, there is a need for the organization to ensure that the CNAs only perform non-clinical tasks devoid of those duties meant for a qualified nurse.

After the recruitment and successful hiring of the nurse assistants, the next step will entail training and inducting them. The induction process will be vital because it will serve as an opportunity for the nurse aides to understand their responsibilities and expectations. The hospital will also take steps to establish their skills and experience, and then tailor the training program to suit their needs. Such an approach is crucial because it will help them to prepare the CNAs adequately so that they are ready for deployment. It is important to note that training enhances CNAs skillset so that they do not compromise the safety of the patients that they handle (Wilberforce et al., 2017). The training should be continuous and needs-based to ensure that the nurse aides have the right skills and competencies. Apart from that aspect, there will be a sensitization program to inform both the nurses and the support staff of the way they are supposed to collaborate and coexist in the clinical environment. It is at this point that the hospital management would need to clarify that the scope of the nurse aides’ work is limited to non-clinical activities. Thus, such a clarification will be critical in avoiding instances in which nurses delegate clinical activities to the nurse assistants.

The implementation of the nurse aide project will take 12 months. During the first two months of the project, the hospital will undertake recruitment, screening, and hiring of the nurse aides. The following four months will feature on-site training for the successful candidates to examine their competency and suitability for the job. This training will be critical because it will make it possible to impart the hospital’s values on the recruits and encourage them to develop a commitment to patient safety to enhance the best patient outcomes. After the training, the nurse aides will be deployed to their various work stations, during which they will be on probation for six months. The probation period will provide the nurse leadership with an opportunity to assess the work of the nurse assistants and to evaluate their efficacy with the rest of the team. It will also be an opportunity to address concerns related to the addition of the new members to make them valuable players to the team.

Implementing the intervention plan will involve the responsibilities of several individuals. Firstly, nurse leaders will be in charge of the training and placement of nurse aides. Secondly, the nurses will be tasked with supervising the nurse aides in their respective areas. Each nurse will communicate the feedback on the performance of the nurse assistants to the nurse managers who will then make decisions to improve the efficiency and effectiveness of the nurse aides. The nurse managers will also communicate with the support aides and advise them on areas of possible improvement to guarantee patient safety and quality of outcomes.

Since the implementation of the project will involve various stakeholders, it is essential to incorporate the transformational leadership theory to help with its execution. The theory is useful because a leader works with teams to identify gaps and a need for change, and then inspires the team to execute the desired transformation (Xu, 2017). According to Xu (2017), the model also encourages active communication and the sharing of feedback to facilitate inclusive decision-making. Therefore, applying such a theory to the implementation of this initiative will enhance the outcomes.

Stakeholders

            The implementation of this project will include several stakeholders who will be central to its success. Firstly, the entire hospital leadership has a vital role to play in the project because they have to sanction every project before its implementation. Secondly, the nurse leaders in the organization will be tasked with the training and deployment of the nursing aides. Nurses comprise the third group of stakeholders with the role of supervising the support workers and ensuring that they perform their duties based on the plan. Besides, all the stakeholders should play their roles to ensure that the project succeeds. The nurse manager will be tasked with the overall responsibility of the project and reporting on the progress to the hospital management. Hence, the nurse manager should adopt transformational leadership to inspire and encourage the team to embrace the project and implement it as planned.

Resources Needed to Implement Plan

            Since the implementation of the initiative requires resources, the most critical resources, in this regard, will include funds to hire and pay the nursing assistants. The hospital should set aside adequate funds to facilitate the hiring of the required staff. Apart from paying such funds, the firm will engage experts throughout the project. Several activities are necessary, including recruitment, hiring, and training of the new staff and the project’s budget is presented in table 1 below. Therefore, the process will involve staff, including nurses and employees, from the human resources department. While funding and hiring comprise the main resource requirements for the project, the organization will also have other needs for the project, such as training materials and uniforms for the new employees. Overall, the required resources should be availed at the right time to ensure that the initiative succeeds.

Table 1: Project Budget

Evaluation Plan

            When implementing an initiative, it is essential to have an evaluation plan to monitor and assess its progress. In this case, the nurse manager will administer regular questionnaires and conduct interviews with the nurses and nurse assistants to evaluate the project. The interviews will provide information about their experiences with the nurse aides and how the latter affects their ability to provide quality patient care. They will also fill anonymous questionnaires, which will allow the nurses to express their opinions in confidence without fear of victimization. The same approach will apply to assistants, who will be requested to reveal their opinions about how they collaborate with nurses during service delivery. Apart from the information from the nurses and support workers, the nurse manager will also consider patient safety and quality indicators such as missed nursing care incidents and readmissions to acquire a better assessment of the impact of hiring the support workers.

Conclusion

The use of nurse aides can help to address the problem of nurse shortages temporarily. However, the support workers are only useful if they play a complementary role and not as substitutes for nurses. The findings from the literature indicate that nurse aides should help with non-clinical tasks such as patient hygiene because they can compromise patient safety if encouraged to provide nursing care. Therefore, the hospital should hire nurse aides to help nurses when providing care to patients. The initiatives will draw various stakeholders, including the management of the entity who will sanction the project, nurses who will supervise the nurse aides, and the nurse manager as the individual charged with the initiative’s overall responsibility. The nature of the project makes it necessary to incorporate the transformative leadership theory since it facilitates the participation of every member of the team and their involvement in decision-making. Going forward, organizations need to reconsider the role of nursing aides, their training, as well as competencies. The management should desist from deploying nurse assistants to nursing roles to avoid compromising patients’ safety. After all, it is only possible to determine the effectiveness of nurse aides if they are assigned their proper roles.

References

American Association of Colleges of Nursing. (2019). Nursing shortage. Retrieved from https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage

Ball, J. (2017). Nurse staffing levels, care left undone, and patient mortality in acute hospitals. [Doctoral Thesis, Karolinska Institutet]. Retrieved from https://pdfs.semanticscholar.org/76a8/9bb72cdbf4a12cbe1fea3f0d4a17b36a6573.pdf

Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2013). ‘Care left undone’during nursing shifts: Associations with workload and perceived quality of care. BMJ Quality & Safety, 23(2), 116-125. http://dx.doi.org/10.1136/bmjqs-2012-001767

Buerhaus, P. I., Skinner, L. E., Auerbach, D. I., & Staiger, D. O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40-46.

Bureau of Labor Statistics. (2019). Registered nurses. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm

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Duffield, C., Roche, M., Twigg, D., Williams, A., Rowbotham, S., & Clarke, S. (2018). Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment. Journal of Clinical Nursing, 27(19-20), 3768-3779. https://doi.org/10.1111/jocn.14632

Griffiths, P., Ball, J., Murrells, T., Jones, S., & Rafferty, A. M. (2016). Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: A cross-sectional study. BMJ Open, 6(2). http://dx.doi.org/10.1136/bmjopen-2015-008751

Institute of Medicine. (2011). The future of nursing. Washington, D. C: Author.

Koy, V., Yunibhand, J., Angsuroch, Y., & Fisher, M. L. (2015). Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: Literature review. International Journal of Research in Medical Sciences, 3(8), 1825-1831. http://dx.doi.org/10.18203/2320-6012.ijrms20150288

Roche, M. A., Friedman, S., Duffield, C., Twigg, D. E., & Cook, R. (2017). A comparison of nursing tasks undertaken by regulated nurses and nursing support workers: A work sampling study. Journal of Advanced Nursing, 73(6), 1421-1432. https://doi.org/10.1111/jan.13224

Sarre, S., Maben, J., Aldus, C., Schneider, J., Wharrad, H., Nicholson, C., & Arthur, A. (2018). The challenges of training, support and assessment of healthcare support workers: A qualitative study of experiences in three English acute hospitals. International Journal of Nursing Studies, 79, 145-153. https://doi.org/10.1016/j.ijnurstu.2017.11.010

Wilberforce, M., Abendstern, M., Tucker, S., Ahmed, S., Jasper, R., & Challis, D. (2017). Support workers in community mental health teams for older people: Roles, boundaries, supervision and training. Journal of Advanced Nursing, 73(7), 1657-1666. DOI: 10.1111/jan.13264

Xu, J. (2017). Leadership theory in clinical practice. Chinese Nursing Research, 4(4), 155-157. doi: 10.1016/j.cnre.2017.10.001

Zhang, X., Tai, D., Pforsich, H., & Lin, V. W. (2018). United States registered nurse workforce report card and shortage forecast: A revisit. American Journal of Medical Quality, 33(3), 229-236.

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