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Using OR Patient Classification for Staffing Assignments


Abstract

Traditionally, one nurse is assigned per OR. Recent health care reforms and the AORN “Position statement on perioperative safe staffing and on-call practices” require managers to rethink this practice. Staffing levels that are insufficient have been linked to sentinel events. A patient classification system that includes patient acuity and procedure complexity can be used to determine which surgical procedures require more than one RN circulator and offer a scientific basis for increasing staff budgetary requests. The goal is to experience fewer sentinel events while providing better patient care and achieving higher nurse retention.

Continuing Education

Using OR Patient Classification for Staffing Assignments

Lynn Bell, BSN, RN, CNOR

Continuing Education Contact Hours

indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

Event: #15521

Session: #0001

Fee: Members $9.60, Nonmembers $19.20

The CE contact hours for this article expire June 30, 2018. Pricing is subject to change.

Purpose/Goal

To provide the learner with knowledge specific to implementing a patient acuity rating system to guide OR nurse staffing.

Objectives
  • 1.Discuss the relationship of nurse staffing levels to patient outcomes.
  • 2.Compare the traditional staffing model for OR departments with the new patient classification system and OR nurse staffing policies.
  • 3.Explain the cost of recruiting and replacing an RN when a staffing model is not in place.
  • 4.Identify possible process measures for the OR.
  • 5.Explain classification models that improve a nurse manager's ability to accurately assign OR patient acuity.
Accreditation

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Approvals

This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Conflict-of-Interest Disclosures

Ms Bell has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

Sponsorship or Commercial Support

No sponsorship or commercial support was received for this article.

Disclaimer

AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

The European Emergency Care Research Institute Conference, collaborating with the World Health Organization, supports evidence that high-quality health care management is a significant factor in preventing most root causes of sentinel events.1 According to The Joint Commission summary of root causes, staffing levels are linked to 23% of these sentinel events.2 Preventive management of staffing levels can assist in adequate staffing and decrease sentinel events.1

According to the American Association of the Colleges of Nursing, “insufficient staffing is raising the stress level of nurses, affecting job satisfaction, and driving many nurses to leave the profession . . . and looking forward, almost all surveyed nurses see the shortage in the future as a catalyst for increasing stress on nurses (98%), lowering patient care quality (93%) and causing nurses to leave the profession (93%).”3(p3) Perioperative nurses have requested additional nursing help during sole assignment to difficult surgical cases. One example of this is a nurse circulating a procedure for a patient undergoing liver transplantation. This complex surgery requires

  • •two setups;
  • •a large number of instrument trays and supplies;
  • •a multitude of laboratory test and blood requests to be completed and sent because of the patient's acuity;
  • •many pre-prep nursing activities;
  • •complicated sponge, sharps, and instrument counts;
  • •complex equipment; and
  • •demanding surgeons and anesthesia professionals.

Other examples of times when OR nurses have requested an additional RN circulator include assignment to a room with multiple repetitive, fast surgical procedures (eg, myringotomy with pressure equalization [PE] tube placement, pain medication injection procedures); typically, it takes longer to complete the documentation than to perform these procedures. Most likely, the RN circulator would not ask for help because there is none readily available because of understaffing. Pressure for decreased turnover times does not allow RN circulators to catch up between procedures and OR processes emphasize efficiency rather than quality.4 These situations discourage perioperative nurses and should be recognized as an assignment process failure. Managers should evaluate traditional assignments and deliberately examine nurse workloads.

Typically, the traditional method for staffing an OR department (ie, one nurse per OR) does not take into account patient acuity or procedure complexity for the OR nurse, as illustrated in the previous examples. One nurse per OR, regardless of patient acuity or procedure complexity, is no longer acceptable considering the modern health reform movement aimed at achieving best patient outcomes. According to the AORN “Position statement on perioperative safe staffing and on-call practices,” additional staffing may be needed for monitoring surgical patients, complex surgical procedures or patient conditions, and technology demands.5 Available research findings on time savings in OR processes and turnovers indicate that the effect of staffing patterns on surgical patient outcomes needs to be addressed in future research to bolster acceptance of divergence from traditional OR assignment processes.4

A scientific method for staff assignments for OR nurses using surgical patient classifications that are derived from patient acuity and procedure complexity is warranted. This proposed change in staffing requires assigning additional nursing personnel per day compared to the traditional method of assignment. Some surgical procedures require more than one nurse, depending on the patient classification. Relying on extra personnel being free from other work for support does not ensure best practice or outcomes.

Evidence-based management analysis

Dunham-Taylor and Pinczuk6 state that any successful change must explain the rationale for why the change is needed, and explanations are available in the literature. The American Nurses Association (ANA) reports that government health care reimbursement restraints and increasing nurse and faculty shortages have adversely affected hospital nursing practices.7 Nurses are taking care of more patients and working longer hours with less support than in the past. This worsening health care environment not only compromises patient safety, but also contributes to poorer patient outcomes and lower nurse retention. The California legislation for safer nurse-patient ratios and facility-determined safe hospital staffing directives are examples of recent government mandates that attempt to address these effects.7,8 These are steps in the right direction, but more is needed to improve the perioperative nursing environment.

The Agency for Healthcare Research and Quality (AHRQ) reported that lower nurse staffing levels in relation to patient numbers are linked to higher adverse outcome rates.9 The ANA states that adding RNs to staffing has been shown to eliminate nearly one in five of all hospital deaths and to reduce the risk of adverse patient outcomes.7 This is particularly significant with government reductions in payments as a result of health care–associated patient injuries.

According to personnel in AORN's Advocacy and Public Policy department, one of the most important duties of a perioperative manager is to develop an effective staffing plan that addresses unique patient needs and is safe for patients and nurses alike.10 AORN staff members have created standards for safe perioperative staffing, which include basing assignments on individual patient needs, patient acuity, technical demands, and staff member competencies.5 These new recommendations are different from the traditional staffing plans of most OR managers.

Retaining experienced nurses, particularly specialized RNs such as perioperative nurses, is important in light of the increasing need for competent nurses to facilitate best patient outcomes. The ANA offers evidence that linked mandatory staffing plan legislation with nurses’ perception of a positive work environment.7 In an AORN survey, 9% of RNs reported leaving OR nursing jobs because of safety concerns.11 The cost of recruiting and replacing an RN is estimated to be 1.1 to 1.6 times a nurse's annual salary, which was reported as $71,344 in 2012 by the Bureau of Health Professions.7,12-14 Increasing RN staffing can yield $3 billion in cost savings for a hospital as a result of $4 million saved in avoidance of adverse events.7,12-14 This information links staffing plans that RNs perceive to be safer to fewer adverse events and links nurse retention with lower department expenditures.7

California's pioneering steps in the realm of nurse to patient safe staffing ratio mandates has prompted other states to take action. Texas enacted nurse staffing legislation 81R SB 476, which states that “in order to protect patients, support greater retention of registered nurses, and promote adequate nurse staffing, the legislature intends to establish a mechanism whereby nurses and hospital management shall participate in a joint process in regards to nurse staffing.”15

These state laws, along with local institution regulations and nursing organization standards, serve to facilitate the evidence-based management argument for a proposed change for safer staffing assignments using patient acuity and procedure complexity data. One barrier to implementing this method of staffing is that it will translate into an increase in RN staffing numbers on any given day to meet the needs of the surgical patients and surgery schedule, therefore increasing cost. It also will mean increased need for education regarding methods to determine acuity and more time spent determining acuity and evaluating procedure complexity by the nurse manager.

The system for classifying OR patient acuity must show evidence that hospital profits would not be decreased or the facility administrator will not approve the change. Currently, most hospitals are decreasing, not increasing, their budgets because of declining reimbursement and increasing operating costs. This would be a difficult change in practice to sell to leadership without addressing fiscal implications. Mark et al16 studied this question of profitability. They found that a 1% increase in RN full-time equivalents (FTEs) did not adversely affect hospital profit and only increased operating costs by 0.25%. They also found that an increase in non-nursing personnel lowered profits and simultaneously increased operating expenses. This could help strengthen the argument for change.

Effectiveness and efficiency of the plan

Dunham-Taylor and Pinczuk6 state that a successful change in practice must also include how the plan will be evaluated for effectiveness. Historically, the OR is one of the major revenue producers for most hospitals.17 The OR would become more effective and efficient with the proposed assignment changes. Begley et al18 state that effectiveness is concerned with actual delivery of health care services and judgments based on evidence. Some examples of possible process measures for the OR may include number of procedures performed per day, turnover time between procedures, delays in care, patient satisfaction, correct counts, incidence of retained objects, correct-site surgery, infection, episodes of hypothermia, pressure ulcer development, and mortality rates.

The University of Texas Medical Branch (UTMB) at Galveston, for example, tracks these process measures in its OR through nursing and department computer documentation. The department then uses a computer specialist to analyze the data. Specific OR nurse–sensitive indicators (eg. turnover time, correct counts, pressure ulcer development) could be targeted and tracked for effectiveness data. Assigning more than one nurse to high-acuity complex procedures may produce significant changes in one or all of these measurable outcomes.

Begley et al18 also stated that effectiveness data such as these can be used to evaluate any health care system's efficiency and impartiality. One example of a pertinent data outcome might be turnover time in the staffing plan. If the new assignment process reduces turnover time between OR procedures, the surgery schedule will potentially have less nonreimbursable OR time and accommodate more procedures; thus, efficiency increases revenue. More surgical patients could be accommodated for more equitable care.

Implementation and data use

Implementing this OR patient classification and staffing assignment plan would first require a review of patient acuity and procedure complexity, determinants of the OR patient classification number. Historical surgical data for one representative month could serve as the starting point. The anesthesia professional documents the patient's acuity preoperatively in the anesthesia record, usually a day or two before surgery, by using an American Society of Anesthesiologists (ASA) physical status classification system score19:

“Implementing this OR patient classification and staffing assignment plan first requires a review of patient acuity and procedure complexity.”

  • •ASA physical status 1: a normal healthy patient;
  • •ASA physical status 2: a patient with mild systemic disease;
  • •ASA physical status 3: a patient with severe systemic disease;
  • •ASA physical status 4: a patient with severe systemic disease that is a constant threat to life;
  • •ASA physical status 5: a moribund patient who is not expected to survive without the surgery; and
  • •ASA physical status 6: a declared brain-dead patient whose organs are being removed for donor purposes.

The ASA data can easily be extrapolated from the OR files. Next, the manager assesses the procedure for complexity with a proposed ranking as follows:

  • •Procedure complexity 1: one procedure requiring minimal equipment (ie, less than four pieces of equipment);
  • •Procedure complexity 2: one procedure requiring four or more pieces pieces of equipment (or extra documentation; ie, multiple specimens, laboratory tests, blood administration);
  • •Procedure complexity 3: two services or one procedure requiring four or more pieces of equipment plus extra documentation or multiple short procedures (eg, pain injections, PE tube placement); and
  • •Procedure complexity 4: two or more services requiring four or more pieces of equipment plus extra documentation.

The nurse manager then assigns trauma patient classification numbers to each procedure in that month to determine new average RN staffing needs per day. For each surgical patient in the audited month, the sum of the ASA and procedure complexity ranking would be assigned as the OR patient classification number. For example, a patient undergoing a liver resection has an ASA score of 4 plus a procedure complexity score of 2 (ie, 4 + 2 = 6). In this example, the patient's classification number would be 6. Arbitrarily, the OR manager may decide that any patient classification of 5 or greater warrants two RN circulators on a trial basis. This decision and procedure complexity factors may differ according to the hospital.

After the nurse manager has assigned every patient in an audited month a classification number, the next step of implementation is to determine the new average number of RNs needed per day from the month's data. Surgery schedules vary, but an average estimate can be obtained and adjusted with future feedback and evaluations. Patient classification numbers determine how often two RNs are needed in an OR and will drive the average RN-per-day number slightly higher because of additional RN hours needed over the traditional one-RN-per-OR assignment model. For example, in a fictitious audit, OR room five stayed busy for 18 working hours in a 24-hour period, which included setup time, performance of surgery, and cleanup time. However, one of its six-hour procedures required two RNs under the new classification system. The additional six hours of RN time must be added into the 18 hours to reflect the real total RN working time of 24 hours on that particular day. Plugging this more accurate number into calculations for direct-care FTEs should produce a more realistic, safer staffing pattern that should help achieve better patient outcomes and fewer sentinel events.

AORN offers a step-by-step formula for budgeting personnel resources that nurse managers can modify and use to calculate RN FTEs.5 A minor revision to the number of working hours per day must be made to factor in the need for two RNs during certain surgical procedures.17 The number of working hours per day is equal to the total time required for setup, performing the procedure, and cleaning the room afterward for those procedures designated as needing one RN, but equal to twice the time for those procedures assigned two RNs. In the following formula, the total number of working hours per day is the sum of both scenarios, as shown in the previous example. The modified AORN formula is

  • •Step 1. Number of ORs × the total number of working hours per day × the number of working days in a week = the total hours to be staffed.
  • •Step 2. Total hours to be staffed ÷ 40 = the number of required FTEs.
  • •Step 3. FTEs × the benefit hours per FTE per year ÷ 2,080 working hours per year = the number of relief FTEs required.
  • •Step 4. FTEs + relief FTEs = the minimum number of direct-care personnel required.

The nurse manager who produces a monthly schedule for OR personnel can use this formula to make better staffing decisions, help ensure best patient outcomes, increase nursing retention, and substantiate the number of OR nurse FTEs for annual budgets. The new average number of RNs needed would be incorporated into these schedules.

The nurse manager who makes daily assignments would need education in this patient classification system to be able to make daily RN assignments scientifically. Assignments also would include individual nurse competencies. Technical services may be able to program these rating systems into the patient schedule for automatic computer-generated patient classification. Such automation could help decrease the time required for the nurse manager to make assignments.

Financial organizational interdependency

The proposed change is dependent on the hospital budget and the organization's business plan; however, hospitals, health care facilities, and providers nationwide are largely dependent on state and federal revenue and other decreasing funding. As previously stated, these entities, particularly the Centers for Medicare & Medicaid Services, are changing reimbursement rules dependent on patient satisfaction and outcomes. Butler et al20 evaluated 15 relevant studies in a Cochrane Collaboration review and concluded that the addition of specialist nurses in nurse staffing models improved patient outcomes. This information and the previously presented evidence-based management analysis provide a strong case for deliberate, evidence-based OR staffing using the OR patient classification system. This patient classification system also takes into account that not all patients are equal and OR nursing care should be assigned according to patient need and procedure complexity for best outcomes.

Role of nursing nomenclature

For designing a better staffing plan, an OR patient classification system could use the already-established ASA acuity nomenclature, but nursing would have to develop its own standardized perioperative language for rating procedure complexity. Perioperative nurses deal with a tremendous amount of technology and equipment in addition to providing complex patient care. Often, procedure complexity for OR nurses is tied to the technology, in addition to direct patient care. Generally, surgeons and anesthesia professionals have no knowledge of the technology and equipment needed for surgical procedures. Typically, this skill set is unique to the OR nurse.

Developing staffing assignments according to a comprehensive patient classification system would recognize this unique nursing work by combining patient acuity with procedure complexity. Hardiker et al21 report that nursing nomenclature quantifies nursing for better resource management, in this situation, OR staff members. If this OR patient classification is to be standardized, it would logically need to be AORN directed to reflect best OR practice and compatibility across national and international databases.

Equity sources

Begley et al state that “equity is concerned with maximizing fairness in the distribution of services (procedural equity) and minimizing disparities in health (substantive equity).”18(p133) It is not fair to OR patients that OR nurses have to work complex OR procedures without adequate support and managerial planning. Adequate staffing would attract more nurses to work and stay in the ORs. One surgical patient's outcomes should not be better than another's as a result of adequate staffing. These valid concerns need to be examined.

Other sources of equity may need to be found to circumvent today's leaner principles and decreasing health care budgets. One strategy for support is to engage upper leadership personnel by encouraging them to spend time with an OR nurse. At UTMB, for example, there is an annual Nurses’ Week program inviting top-level executives to spend two hours in the OR shadowing a nurse. They see firsthand the fluctuating complexities of the RN workload, and the participant can bring this experience back to the board room, where high-level decisions are made.

Studies could be initiated comparing the topics of OR nursing perceptions or nurse-sensitive patient outcomes before and after the proposed staffing assignment plan using patient classifications has been implemented. Both topics of study are linked to organizational finances; nurse retention for the former, financial reimbursement for the latter. Grants for nursing research such as this are available through many sources, but are easily found on the ANA web site.22

Conclusion

In these uncertain times of health care direction and reimbursement, one thing remains clear: nurses practice because they want to do what is best for patients. The change from making OR nursing assignments in the traditional manner to using an OR patient classification system is a fiscally responsible, evidence-based plan for better RN assignments. It provides scientifically anticipated management support for RNs working in complex procedures with sicker patients or more difficult workloads, encourages nursing retention, and promotes patient satisfaction. Future predictions of nursing shortages and increases in higher acuity patients make implementation of this plan an even more urgent necessity.

Examination

Continuing Education: Using OR Patient Classification for Staffing Assignments

Purpose/Goal

To provide the learner with knowledge specific to implementing a patient acuity rating system to guide OR nurse staffing.

Objectives

  • 1.Discuss the relationship of nurse staffing levels to patient outcomes.
  • 2.Compare the traditional staffing model for OR departments with the new patient classification system and OR nurse staffing policies.
  • 3.Explain the cost of recruiting and replacing an RN when a staffing model is not in place.
  • 4.Identify possible process measures for the OR.
  • 5.Explain classification models that improve a nurse manager's ability to accurately assign OR patient acuity.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation athttp://www.aorn.org/CE.

Questions

  • 1.According to The Joint Commission summary of root causes, staffing levels are linked to ______ of sentinel events.
  • 2.The traditional staffing model for OR departments is
    • a.one RN per OR.
    • b.two RNs per OR.
    • c.one RN per hour of procedure.
    • d.two RNs per hour of procedure.
  • 3.The Agency for Healthcare Research and Quality reported that lower nurse staffing levels in relation to patient numbers are linked to
    • a.lower adverse outcome rates.
    • b.higher adverse outcome rates.
    • c.no change in adverse outcome rates.
    • d.unknown changes in adverse outcome rates.
  • 4.The cost of recruiting and replacing an RN is estimated to be ________ times a nurse's annual salary.
    • a.0.25 to 0.5
    • b.1.1 to 1.6
    • c.2.6 to 3.2
    • d.4.6 to 6.1
  • 5.Some examples of possible process measures for the OR may include
    • 1.number of procedures performed per day.
    • 2.delays in care.
    • 3.episodes of hypothermia.
    • 4.pressure ulcer development.
    • 5.incidence of retained objects.
      • a.1 and 2
      • b.3, 4, and 5
      • c.2, 3, 4, and 5
      • d.1, 2, 3, 4, and 5
  • 6.If a patient has severe systemic disease that is not a constant threat to life, his or her American Society of Anesthesiologists (ASA) Physical Status Classification score would be
    • a.ASA 2.
    • b.ASA 3.
    • c.ASA 4.
    • d.ASA 5.
  • 7.Under author's procedure complexity rating system, a procedure with a score of 3 would be
    • a.one procedure with minimal equipment.
    • b.one procedure requiring four or more pieces of equipment or extra documentation.
    • c.two or more services requiring four or more pieces of equipment plus extra documentation.
    • d.two services or one procedure requiring four or more pieces of equipment plus extra documentation or multiple short procedures.
  • 8.The number of working hours per day is equal to the total time required for setup, performing the procedure, and cleaning the room afterward for those procedures designated as needing one RN, but equal to twice the time for those procedures assigned two RNs.
  • 9.Butler et al evaluated 15 relevant studies in a Cochrane Collaboration review and concluded that the addition of specialist nurses in nurse staffing models improved patient outcomes.
  • 10.Minimizing disparities in health is called ____________ equity.
    • a.asset
    • b.nominal
    • c.procedural
    • d.substantive

Learner Evaluation Continuing Education: Using OR Patient Classification for Staffing Assignments

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

Objectives

To what extent were the following objectives of this continuing education program achieved?

  • 1.Discuss the relationship of nurse staffing levels to patient outcomes. Low 1. 2. 3. 4. 5. High
  • 2.Compare the traditional staffing model for OR departments with the new patient classification system and OR nurse staffing policies. Low 1. 2. 3. 4. 5. High
  • 3.Explain the cost of recruiting and replacing an RN when a staffing model is not in place. Low 1. 2. 3. 4. 5. High
  • 4.Identify possible process measures for the OR. Low 1. 2. 3. 4. 5. High
  • 5.Explain classification models that improve a nurse manager's ability to accurately assign OR patient acuity. Low 1. 2. 3. 4. 5. High

Content

  • 6.To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
  • 7.To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
  • 8.Will you be able to use the information from this article in your work setting? 1. Yes 2. No
  • 9.Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)
  • 9A.How will you change your practice? (Select all that apply)
    • 1.I will provide education to my team regarding why change is needed.
    • 2.I will work with management to change/implement a policy and procedure.
    • 3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.
    • 4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.
    • 5.Other: _____________________
  • 9B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
    • 1.The content of the article is not relevant to my practice.
    • 2.I do not have enough time to teach others about the purpose of the needed change.
    • 3.I do not have management support to make a change.
    • 4.Other: _____________________
  • 10.Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: ______________________

Biography

  • Lynn Bell, BSN, RN, CNOR is perioperative program manager at the University of Texas Medical Branch, Galveston. Ms Bell has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Ancillary

Article Information

DOI

10.1016/j.aorn.2015.03.003

Format Available

Full text: HTML | PDF

© 2015 AORN, Inc

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Publication History

  • Issue online:
  • Version of record online:

Keywords

  • nurse staffing;
  • OR staffing;
  • patient classification;
  • nursing assignments

References

  • 1Emslie S, Knox K, Pickstone M, eds. Improving Patient Safety: Insights From American, Australian and British Healthcare. World Health Organization. http://www.who.int/patientsafety/journals_library/Improving_Patient_Safety.pdf. Accessed February 9, 2015.
  • 2Sentinel event data root causes by event type: 2004–2013. The Joint Commission. http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf. Accessed March 4, 2015.
  • 3Nursing shortage fact sheet. American Association of Colleges of Nursing. http://www.aacn.nche.edu/media-relations/NrsgShortageFS.pdf. Updated April 24, 2014. Accessed February 9, 2015.
  • 4McLaughlin MM. A model to evaluate efficiency in operating room processes. University of Michigan. http://deepblue.lib.umich.edu/bitstream/handle/2027.42/96155/mmmcl_1.pdf?sequence=1. Accessed February 9, 2015.
  • 5AORN guidance statement: perioperative staffing. In Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings. Denver, CO: AORN. 2013, 543–548.
  • 6J. Dunham-Taylor, J.Z. Pinczuk. Financial Management for Nurse Managers. Sudbury, MA: Jones & Bartlett. 2010.
  • 7H.R. 1821—Registered Nurse Safe Staffing Act. American Nurses Association. http://thomas.loc.gov/cgi-bin/query/z?c113:H.R.1821.IH:/. Accessed February 17, 2014.
  • 8YKasprak J. California RN Staffing Ratio Law. Connecticut General Assembly. http://www.cga.ct.gov/2004/rpt/2004-R-0212.htm. Accessed March 4, 2015.
  • 9Hospital nurse staffing and quality of care. Agency for Healthcare Research and Quality. www.ahrq.gov. http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html. Accessed March 4, 2015.
  • 10Federal RN safe staffing act is slow moving. AORN, Inc. Published May 14, 2014. http://www.aorn.org/News.aspx?id=26798. Accessed February 9, 2015.
  • 11RN circulator surveys reveal gaps in RN circulator use. AORN.org. http://www.aorn.org/News.aspx?id=21748. Published October 12, 2011. Accessed March 4, 2015.
  • 12The registered nurse population. US Department of Health and Human Services Health Resources and Services Administration. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf. Published September 2010. Accessed March 4 2015.
  • 13Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 364(11):1037-1045.
  • 14J. Needleman, P.I. Buerhaus, M. Stewart, K. Zelevinsky, S. Mattke. Nurse staffing in hospitals: is there a business case for quality?. Health Aff (Milwood). 2006; 25, (1): 204–211, http://content.healthaffairs.org/content/25/1/204/T4.expansion.html, Accessed March 4, 2015.
  • 15S.B. No. 476. Texas Legislature Online. http://www.legis.state.tx.us/tlodocs/81R/billtext/html/SB00476F.htm. Accessed February 17, 2015.
  • 16B.A. Mark, D.W. Harless, M. McCue, Y. Xu. A longitudinal examination of hospital registered nurse staffing and quality of care. Health Serv Res. 2004; 39, (2): 279–300.
  • 17V. Butler, C. Clinton, H.K. Sagi, R. Kenney, W.K. Barsoum. Applying science and strategy to operating room workforce management. Nurs Econ. 2012; 30, (5): 275–281.
  • 18C.E. Begley, D.R. Lairson, R.O. Morgan, P.J. Rowan, R. Balkrishnan. Evaluating the Healthcare System: Effectiveness, Efficiency, and Equity. 4th ed.. Chicago, IL: Health Administration Press. 2013.
  • 19ASA physical status classification system. American Society of Anesthesiologists. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed February 17, 2014.
  • 20M. Butler, R. Collins, J. Drennan, et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database Syst Rev. 2011; 7: CD007019, http://dx.doi.org/10.1002/14651858.CD007019.pub2.
  • 21N.R. Hardiker, D. Hoy, A. Casey. Standards for nursing terminology. J Am Med Inform Assoc. 2000; 7, (6): 523–528.
  • 22Opportunities for research funding. American Nurses Association. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-Your-Practice/Research-Toolkit/Research-Funding. Accessed February 10, 2015.

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