It is clear from recent studies by Dr. Linda Aiken and others that the number of patients a nurse cares for as well as the qualifications of the nurse both directly affect the quality and safety of care delivered. Staffing issues are of prominent importance in the world of health care today and, from input we receive from all over the country, these issues are a major concern for our SPN members. Pediatric nurses (and hopefully, all administrators), know that the care of children requires different staffing considerations than the care of adults. The Society of Pediatric Nurses strongly holds this belief and at our October 2003 Board Meeting, a new Position Statement on “Safe Staffing in Pediatric Settings” was approved.
After careful review and consideration of this issue, the SPN Clinical Practice Committee and SPN Board of Directors have crafted a Position Statement that delineates the important factors that must be taken into account in determining safe staffing levels in each pediatric setting. While we have determined that there is no “magic, one-size-fits-all” ratio for safe staffing that can apply to all general pediatric settings, we have determined that there are crucial factors that must always be considered in determining safe staffing levels for infants, children, and adolescents. We also believe that appropriate training in pediatrics is necessary for a nurse to safely care for patients in pediatric settings. It is our intent that this Position Statement (along with pertinent state regulations and the resources cited and endorsed in this document) will be a guide and a resource for pediatric nurses and administrators involved in staffing decisions.
Because this is such an important issue in today’s health care system, and because of the increasing recognition of the vital role that nurses play in enhancing and safeguarding the health and well-being of patients, new documents and reports continue to evolve. In November of 2003, (shortly after the SPN Board had approved the following position statement) the Institute of Medicine released a new report entitled “Keeping Patients Safe: Transforming the Work Environment of Nurses” (available at http://www.nap.edu). This report highlights needed changes in the way nurse staffing hours are established and also calls for mandatory limits on nurses’ work hours. The report describes ways to strengthen the work environment thereby reducing problems that threaten patient safety. SPN will continue to monitor the latest reports and research in this area and will continue to update and revise our position statements as well as inform our members of major new information. Please visit our website for copies of this Position Statement as well as for links to the IOM report and other reports as they become available.
Linda A. Lewandowski, PhD, RN, President, Society of Pediatric Nurses
The society of pediatric nurses position statement
Safe staffing for pediatric patients
Increasing attention is being focused on the impact of adequate nurse staffing on patient outcomes and the multiple factors that can affect safe staffing. At the same time that mounting research is supporting the vital role that nurses play in patient outcomes, the national nursing shortage is negatively affecting the number of nurses available (
American Nurses Association 2000,
American Nurses Association
Nursing staffing and patient outcomes. Author, Washington, DC2000
Buerhaus et al 2000).
- Buerhaus P.I.
- Staiger D.O.
- Auerbach D.I.
Implications of an aging registered nurse workforce.
Journal of the American Medical Association. 2000; 283: 2948-2954
The Institute of Medicine’s report of September 1999 first called the public’s attention to the problem of increased patient morbidity and mortality related to errors occurring within healthcare delivery systems (
Institute of Medicine 1999). Since this time there has been a growing emphasis on patient safety, process improvement, and the potential effects of adequate staffing. In 2002, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) supported this patient safety initiative by introducing a standard requiring hospitals to measure performance indicators of staffing effectiveness linked to patient outcomes (
Institute of Medicine
To err is human. Author, Washington, DC1999
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) 2002).
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
Comprehensive accreditation manual for hospitals. Author, Oakbrook Terrace, IL2002
Studies by Aiken and colleagues demonstrated an increase of 30% in mortality risk for patients being cared for by nurses with average workloads of eight or more patients compared with those patients being cared for by nurses with a workload of four or fewer patients (2002, 2003). While these studies focused on adult patients, the same concerns exist regarding the relationships between adequate staffing and outcomes in pediatric patients.
The Society of Pediatric Nurses (SPN) believes the following additional factors are of critical importance regarding safe staffing for pediatric patients:
- •The acuity and intensity of nursing resources required to care for children have been growing steadily over the last decade (National Association of Children’s Hospitals and Related Institutions (NACHRI) 2003).National Association of Children’s Hospitals and Related Institutions (NACHRI)Clinical Practices Service Program. 2003
- •The number of children living below the poverty level is higher now than 25–30 years ago and contributes to deficits in primary and preventive health care and results in increased healthcare issues and higher acuity for these children (Children’s Defense Fund December 2002).Children’s Defense FundBasic facts onpoverty. Author, Washington, DC2002
- •The multitude of settings providing pediatric care and the wide range of resources available in each setting greatly affect the type and number of nursing staff required to care for any given patient population.
SPN believes that all children and their families should receive high quality family-centered care. As an advocate for patients, families, and the pediatric nursing profession, SPN endorses the following recommendations:
- 1.No single published ratio for nurse staffing is automatically applicable in all settings where children receive care. Published recommendations for staffing ratios must be carefully evaluated for the particular pediatric setting since these ratios may inadvertently minimize the complexity and multitude of issues that must be considered in the care of pediatric patients and their families.
- 2.The professional registered nurse must be considered an essential member of the team providing care for children and their families; staffing plans must reflect this vital role (American Nurses Credentialing Center (ANCC) 2003).American Nurses Credentialing Center (ANCC)The Magnet Recognition Program For Excellence in Nursing Service Health Care Organization, Instructions and Application Process. Pub # MAGMAN03.Author, Washington, DC2003
- 3.Staffing plans and assignments should be developed which promote developmentally appropriate, high quality care for children and families.
- 4.While the specific details of these staffing plans will vary with individual patient needs and facility resources, SPN believes the following factors should be considered in all staffing situations:
- a.Number and acuity of patient population.
- b.Assessment of patient needs including special developmental, physiological, psychosocial, and learning needs of children and their families.
- c.Availability of specialized pediatric equipment and supplies to provide the necessary care and the availability of other support services to assist in the delivery of care (e.g., child life, social services, chaplain services).
- d.Staff competency, specifically the extent of experience and specialized pediatric training of available staff.
- e.Family involvement and/or the family’s special needs related to meeting the healthcare needs of the child (Lewandwoski and Tesler 2003).
Family-centered care:Putting it into action: The SPN/ANA guide to family-centered care. American Nurses Publishing, Washington, DC2003
- Lewandwoski L.A.
- Tesler M.D.
- f.Comparable pediatric staffing benchmark data and/or staffing guidelines from other pediatric-focused professional organizations should be used if at all possible (National Association of Children’s Hospitals and Related Institutions (NACHRI) 2003,National Association of Children’s Hospitals and Related Institutions (NACHRI)Clinical Practices Service Program. 2003National Association of Neonatal Nurses 1999); theNational Association of Neonatal NursesMinimum staffing in NICUs. Author, Glenview, IL1999American Academy of Pediatrics 2003,American Academy of Pediatrics
Clinical report Facilities and equipment for the care of patients in a community hospital.Pediatrics. 2003; 111: 1120-1122American Academy of Pediatrics 2002,American Academy of Pediatrics
Policy statement Guidelines for pediatric cardiovascular centers.Pediatrics. 2002; 109: 544-549Aiken et al 2002,
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.Journal of the American Medical Association. 2002; 288: 1987-1993American Academy of Pediatrics 1999,American Academy of Pediatrics
- Aiken L.H.
- Clark S.P.
- Sloane D.M.
- Sochalski J.
- Silber J.H.
Policy statement Guidelines for pediatric perioperative anesthesia environment.Pediatrics. 1999; 103: 512-515American Academy of Pediatrics 1993.American Academy of Pediatrics
Policy statement Guidelines and levels of care for pediatric intensive care units.Pediatrics. 1993; 92: 166-175
- 5.Nurses caring for pediatric patients must have appropriate education and experience to demonstrate competency in the care of this highly-specialized patient population. The core concepts as cited in the following sources should be included in education and training:
- ◦Scope and Standards of Pediatric Nursing Practice (American Nurses Association 2003)American Nurses AssociationScope and standards of pediatric nursing practice. American Nurses Publishing, Washington, DC2003
- ◦Core Curriculum for the Nursing Care of Children and Their Families (Broome and Rollins 1999)
Core curriculum for the nursing care of children and their families. Jannetti Publications, Pitman, NJ1999
- Broome M.
- Rollins J.
- ◦Standards and Guidelines for Pre-Licensure and Early Professional Education for the Nursing Care of Children and Their Families (Woodring 1998).
Standards and guidelines for pre-licensure and early professional education for nursing care of children and their families. U.S. Government Printing Office. DDHS, Bureau of MCH, Document, #H112R77, Washington, DC1998
- Woodring B.
- 6.Organizations and nursing staff providing care for pediatric patients should commit to ongoing maintenance of nursing staff’s clinical competency through continuing education that ensures a current knowledge base of issues and trends in pediatric care delivery.
- 7.Organizations should work to establish practice environments characterized by open communication, teamwork, and effective collaborative problem solving to address nurse staffing issues and ensure safe, effective care for children and families.
- 8.Nurses are encouraged to assume professional accountability for their own practice. Nurses have the accountability for the following:
- ◦Being an advocate for the role of the registered professional nurse
- ◦Being knowledgeable of state practice acts
- ◦Being knowledgeable of the mechanisms available to address potential staffing issues.
- Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.Journal of the American Medical Association. 2002; 288: 1987-1993
- Clinical report.Pediatrics. 2003; 111: 1120-1122
- Policy statement.Pediatrics. 2002; 109: 544-549
- Policy statement.Pediatrics. 1999; 103: 512-515
- Policy statement.Pediatrics. 1993; 92: 166-175
- Scope and standards of pediatric nursing practice. American Nurses Publishing, Washington, DC2003
- Nursing staffing and patient outcomes. Author, Washington, DC2000
- The Magnet Recognition Program For Excellence in Nursing Service Health Care Organization, Instructions and Application Process. Pub # MAGMAN03.Author, Washington, DC2003
- Core curriculum for the nursing care of children and their families. Jannetti Publications, Pitman, NJ1999
- Implications of an aging registered nurse workforce.Journal of the American Medical Association. 2000; 283: 2948-2954
- Basic facts onpoverty. Author, Washington, DC2002 (December)
- To err is human. Author, Washington, DC1999
- Comprehensive accreditation manual for hospitals. Author, Oakbrook Terrace, IL2002
- Family-centered care:Putting it into action: The SPN/ANA guide to family-centered care. American Nurses Publishing, Washington, DC2003
- Minimum staffing in NICUs. Author, Glenview, IL1999
- Clinical Practices Service Program. 2003 (Available from http:\\www.childrenshospitals.net/nachri)
- Standards and guidelines for pre-licensure and early professional education for nursing care of children and their families. U.S. Government Printing Office. DDHS, Bureau of MCH, Document, #H112R77, Washington, DC1998
© 2003 Published by Elsevier Inc. All rights reserved.