Issues up close

There are a multitude of tools available to nurses that capture, analyze, and determine nurse staffing, whether to create a staffing plan or evaluate its effectiveness. Within that multitude, ANA’s Principles for Nurse Staffing, 2nd Edition, stands out in establishing the critical nature of nurse staffing and the capability of all nurses to advocate for effective staffing. The ANA cornerstone documents Code of Ethics for Nurses With Interpretive Statements (2001) and Nursing: Scope and Standards of Practice, 2nd Edition, give nurses the leverage and rationale to advocate for nurse staffing. These unique professional tools create momentum for nurses in their quest to determine and achieve the best possible staffing to optimize outcomes.

ANA’s Principles: The framework for staffing policy and advocacy

ANA strongly believes a new narrative in staffing policy is necessary. Nurse staffing fits squarely in the realm of better care, improved health, and lower costs and is a critical component of hospital and healthcare facility operations that adds value. When nurse staffing is looked at as part of the process to achieving outcomes, personnel costs become muted by the rewards for the quality of care.

The recently updated ANA’s Principles for Nurse Staffing, 2nd Edition strengthens the focus on the work environment and broadens it to include all nursing practice settings. ANA policy recognizes that any evidence-based approach to achieving appropriate nurse staffing is acceptable; the ultimate goal is not necessarily the process that results in better staffing, but the outcome of achieving optimal care. Legislative, regulatory, and accreditation forces can drive changes that improve staffing.

As delivery systems evolve toward a greater focus on delivery of better care, so too must attitudes toward nurse staffing. Appropriate nurse staffing must be the purview of all who have a stake in patient safety, quality care, and better health. ANA’s Principles provides policy direction that all nurses, managers, policy makers, and consumers can use to address nurse staffing.

Code of Ethics: A guide to nursing responsibilities for safe staffing

Appropriate nurse staffing is supported from many perspectives throughout the Code of Ethics for Nurses With Interpretive Statements. Respect for persons lays the groundwork of the Code, which includes the requirement to maintain “caring and compassionate relationships with a commitment to the fair treatment of individuals, to integrity preserving compromise, and to resolving conflict” (Interpretive Statement 1.5, page 9). It acknowledges that administrator is one of many nursing roles; calls for treating colleagues, employees, and others with respect and compassion; and precludes disregarding the effect of one’s actions on others.

The Code addresses nurses’ competing loyalties in the workplace, including situations of conflicting expectations from patients, families, physicians, colleagues and, in many cases, healthcare organizations and health plans (Interpretive Statement 2.2, page 10). More specifically, it states:

Nurses should actively promote the collaborative multi-disciplinary planning required to ensure
the availability and accessibility of quality health services to all persons who have needs for health care (Interpretive Statement 2.3, page 11).

Further, the code states: “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

Nursing is responsible and accountable for assuring that only those individuals who have demonstrated the knowledge, skill, practice experiences, commitment, and integrity essential to professional practice are allowed to enter into and continue to practice within the profession. Nurse administrators are responsible for assuring that the knowledge and skills of each nurse in the workplace are assessed prior to the assignment of responsibilities.
The nurse has a responsibility to implement and maintain standards of professional nursing practice. Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review (Interpretive Statement 3.4, page 13).

Nurses should also be active participants in the development of policies and review mechanisms designed to promote patient safety, reduce the likelihood of errors, and address both environmental system factors and human factors that present increased risk to patients.

The section on responsibility and accountability addresses appropriate nurse staffing, including delegation. It states: “Nurses functioning in management or administrative roles have a particular responsibility to provide an environment that supports and facilitates appropriate assignment and delegation” (Interpretive Statement 4.4, page 17).

Another section considers the preservation of integrity, especially as it relates to patterns of institutional behavior or professional practice that compromise the integrity of all its nurses. “Where patterns of institutional behavior or professional practice compromise the integrity of all its nurses, nurses should express their concern or conscientious objection collectively to the appropriate body or committee” (Interpretive Statement 5.4, page 20).

The section continues with explicit direction about responsibility for the healthcare environment.

Nurse administrators have a particular responsibility to assure that employees are treated fairly and that nurses are involved in decisions related to their practice and working conditions. Acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice. Nurses should not remain employed in facilities that routinely violate patient rights or require nurses to severely and repeatedly compromise standards of practice or personal morality (Interpretive Statement 6.3, page 21).

Scope and Standards of Nursing: Tenets, competencies that support safe staffing

There is further evidence for safe staffing in Nursing: Scope and Standards of Practice, 2nd Edition. The document outlines expectations of the professional role of the registered nurse (RN), regardless of specialty or practice setting. Aspects of both the scope of nursing and the standards of professional practice and performance speak to the professional responsibility of nurses to advocate for appropriate nurse staffing. Additionally, employers must partner with RNs to create an environment that supports achievement of these standards.

The scope of nursing practice includes the tenets of nursing practice and nursing’s societal and ethical dimensions that involve nurse staffing. One of the five tenets of nursing practice is the following: “A strong link exists between the professional work environment and the registered nurse’s ability to provide quality health care and achieve optimal outcomes” (page 5). This tenet speaks to the evidence-based assertion that a healthy work environment, which includes appropriate nurse staffing, is essential to quality care. According to this tenet, RNs can enhance care by advocating for better staffing and avoiding the negative consequences that poor staffing can cause.

The standards of professional practice describe the standards and competencies related to the nursing process. RNs use the process to scientifically analyze and describe staffing needs in their setting. These standards assist nurses in assessing the situation, collecting evidence, articulating the problem, and outlining the desired outcome for a plan as related to staffing needs.

The standards of professional performance articulate RNs’ involvement in the work environment, patient-care environment, and care team. All of these factors enhance the ability to attend to the nursing process, whether in a direct care situation or improving a situation, such as staffing. Specifically, nurses can leverage Standard 7—Ethics, Standard 11—Communication, Standard 12—Leadership, and Standard 15—Resource Utilization. The competencies associated with these standards can guide nurses on the most effective ways to analyze, articulate, and advocate for nurse staffing.

Powerful tools

As professionals, RNs nurses have the ability to scientifically and collaboratively articulate the staffing needs of their setting. The cornerstone documents are powerful tools for nurses to support their right and rationale to advocate for staffing. With these documents as a guide, nurses can capitalize on the art and science of nursing and achieve the best staffing that optimizes patient outcomes.

Laurie Badzek is director of the ANA Center for Ethics and Human Rights. Katie Brewer is a senior policy analyst at ANA. Cheryl Peterson is director of practice and policy at ANA. Martha Turner is assistant director of the ANA Center for Ethics and Human Rights.

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