Mandated Nurse-Patient Ratios

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    Every nurse has to decide whether to support mandated nurse-patient ratios or support the status quo. It's time to speak up for patient safety and nurse sanity.

    Mandated Nurse-Patient Ratios

    Ashley sank into a chair in the breakroom on her MedSurg unit in a large hospital in Florida. It was 0330, 8 ½ hours into her shift. She had not yet taken a break of any sort, including a bathroom or hydration break. In staff meetings, it was repeatedly emphasized never to miss a lunch break or stay overtime, but in the moment, it was hard to manage. Right now her stress was so high that as soon as she sat down, she struggled to keep back the tears.

    Of her 7 patients, she had had two rapid responses (RRTs) and one patient was sent to ICU with sepsis. She was pretty sure she had missed the early signs of sepsis in her post-op patient, with an increased heart rate and infected wound. It's just that there was too much information and she was cognitively overloaded.

    Her phone buzzed in her scrub pocket. Wearily she picked up the call. It was Laura, the charge nurse, sounding stressed out. "Ashley, I need you to take an ED admit in Room 4123. Is the room clean? Can you take report now, please?"

    Across the country in California, Lindsay works on a similar MedSurg unit. Because she works in California, she can never be assigned more than 5 patients. Her day was busy and at times crazy. She knew that adding on 2 more patients would make it unmanageable. Thank goodness it was 5 patients, and not 7. During lunch breaks her patients were covered by break nurses and she did not take her phone into the breakroom.

    Why is there such disparity? How is it that a patient with exacerbated CHF on Tele in Alabama has a nurse with five other patients and a patient with exacerbated CHF on Tele in California has a nurse with only 3 other patients?

    The reason is that California has mandated nurse-patient ratios in every hospital unit. ICU is 1:2, SDU 1:3, Tele 1:4, Med Surg 1:5.

    Patient Perspective

    If you were a patient and could choose, would you choose a nurse who has 4 patients or 7 patients? If your baby was in NICU, would you want your child to have a nurse with 1 other infant, or 2 other infants?

    There is abundant evidence to show that patients suffer when nurses have too many patients. The following is a quote from Ruth Neese's Talking Points for Safe Staffing.

    1. Cost to replace a single nurse burned out by overwork from understaffing was in excess of $80,000/nurse in 2012 (Twibell & St. Pierre, 2012).
    2. The difference between 4:1 and 8:1 patient-to-nurse staffing ratios is approximately 1,000 patient deaths (Aiken, Clarke, Sloan et al., 2002).
    3. Patients on understaffed nursing units have a 6% higher mortality rate (Needleman et al., 2011). This risk is higher within the first 5 days of admission (Needleman et al).
    4. An increase of one RN FTE per 1000 patient days has been associated with a statistically significant 4.3% reduction in patient mortality (Harless & Mark, 2010).
    5. Adding one patient to a nurse's workload increases the odds for readmission for heart attack by 9%, for heart failure by 7%, and for pneumonia by 6% (McHugh, 2013).
    6. Lower patient-to-nurse staffing ratios have been significantly associated with lower rates of:
      1. Hospital mortality;
      2. Failure to rescue;
      3. Cardiac arrest;
      4. Hospital-acquired pneumonia
      5. Respiratory failure;
      6. Patient falls (with and without injury); and
      7. Pressure ulcers (Aiken, Sloane, et al., 2011; Cho et al., 2015; Kane et al., 2007; Needleman, Buerhaus, Stewart, Zelevinsky & Mattke, 2006; Rafferty et al., 2007: Stalpers et al., 2015)

    7. Higher numbers of patients per nurse was strongly associated with administration of the wrong medication or dose, pressure ulcers, and patient falls with injury (Cho, Chin, Kim, & Hong, 2016).
    8. Rising patient volumes, higher patient acuity, and reduced resources lead to nurse burnout and fatigue, resulting in first year nurse turnover rates of approximately 30% and second year rates up to 57% (Twibell & St. Pierre, 2012)."

    Action

    Mandated nurse-patient ratios are a matter of public safety. There are regulated practice safeguards in place for airline pilots and truck drivers and other industries. Why not nursing?

    Historically nurses are a silent workforce who have allowed employers to determine clinical practice. But that is changing. The time for change is now. On April 25th and 26th 2018, nurses around the country will gather in Washington D.C. for the 3rd annual rally to urge lawmakers to enact safe staffing ratios. In numbers, we have strength and will be acknowledged.

    Come join allnurses in Washington DC! Meet up with the allnurses team who will be filming and interviewing, and myself, Nurse Beth! Dr. Laura Gasparis, whose conferences many of us ICU nurses have attended, is the lead speaker.

    By standing together, we can bring about needed reform. Will you be a part and bring about change as the nurses did in California?

    Be sure and read Male Nurse Disgusted by Female Nurses for a unique point of view on working conditions and ratios.

    What else can you do? So many things!

    Easily find out who your legislators are and make a call.

    Write a letter to support H.R. 2392 and S. 1063 Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017 legislative bills. Legislators respond to topics based on the number of phone calls and mail from their constituents.

    While you are in Washington, make an appointment to see your legislator.

    Share this article on social media. Use hashtags #NursesTakeDC and #allnursesSTRONG

    Please watch the following video for more information on NursesTakeDC 2018. Like this article if it spoke to you, and comment below. Thanks much.





    Neese, R (2016). Talking points for Safe Staffing. Retrieved January 12018. Nurse Patient Ratios | Talking Points for Safe Nurse Staffing
    Last edit by Nurse Beth on Jan 18
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    About Nurse Beth, MSN, RN

    Nurse Beth blogs at nursecode.com

    Nurse Beth has '20+' year(s) of experience and specializes in 'Med Surg, Tele, ICU, Ortho'. Joined Mar '07; Posts: 1,201; Likes: 3,605.

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    88 Comments

  3. by   ICUman
    With all the expenses lost in replacing burnt out nurses, fines for hospital acquired pressure ulcers, medication errors, and everything else listed above, etc., how come hospitals haven't realized reducing nurse to patient ratios will actually *save* the hospital money?

    Is it more expensive really just to hire a few extra nurses? All the hospital scores and safety numbers would rise, including HCAHPS.

    It would be a win-win for everyone. What am I missing?
  4. by   Axgrinder
    We have been consistently under staffed on evening shift since October ... management says "the call volume doesn't indicate higher staffing ratios" than 1.5 nurses for this shift - but calls come in clusters, and many are very involved and/or behavioral health patients ... am I (present - not the number crunchers) missing something?

    Dreading my shift tonight (as per usual lately) ...

    Feeling stressed, irritable and burned out to the Nth degree ...
  5. by   Daisy4RN
    I have worked in California in the past and can tell you even with ratios it is too much. It has become worse over the years because of gov. regulations, hospital p/p, and the push for pt. satisfaction, and higher pt acuity. I can not even imagine having 7 med-surg patients, this is crazy and unsafe.
  6. by   ROSE BSN
    Staffing ratios are a must., but it must include other areas such as long term care. I would like to hear what everyone's opinion is for appropriate ratios for long term care, assisted living, and rehabilitation,
  7. by   Nurse Beth
    Quote from ICUman
    With all the expenses lost in replacing burnt out nurses, fines for hospital acquired pressure ulcers, medication errors, and everything else listed above, etc., how come hospitals haven't realized reducing nurse to patient ratios will actually *save* the hospital money?

    Is it more expensive really just to hire a few extra nurses? All the hospital scores and safety numbers would rise, including HCAHPS.

    It would be a win-win for everyone. What am I missing?
    I don't know because I'm missing the same thing! Baffled
  8. by   Nurse Beth
    Quote from ROSE BSN
    Staffing ratios are a must., but it must include other areas such as long term care. I would like to hear what everyone's opinion is for appropriate ratios for long term care, assisted living, and rehabilitation,
    Yes. I think it will spread if we stay strong.
  9. by   Nurse Beth
    Quote from Daisy4RN
    I have worked in California in the past and can tell you even with ratios it is too much. It has become worse over the years because of gov. regulations, hospital p/p, and the push for pt. satisfaction, and higher pt acuity. I can not even imagine having 7 med-surg patients, this is crazy and unsafe.
    I completely agree. The proposed legislation calls for 1:3 Tele, 1:4 MedSurg!
  10. by   AngelKissed857
    Also needs to include correctional facilities! Try delivering safe care with a ratio of 1:850!
  11. by   FSZ Student Nurse
    Quote from AngelKissed857
    Also needs to include correctional facilities! Try delivering safe care with a ratio of 1:850!
    YIKES!!!
  12. by   joseyjo
    Just reading this sounds like a dream come true. I would LOVE to have a 1:4 ratio! What good care I could give my patients...

    I work on an oncology/telemetry unit. We have 1:6 ratios and as a 1st year nurse I can tell you I can constantly overwhelmed. I have taken a lunch break 2x in my 7 months (both times cut short by calls from the floor). Everyone is expected to eat at their desk while charting (and not let patients see of course). I usually only get to go pee 1 or 2x in 12 hours.

    I love my job and my floor, but we need more nurses and a lower ratio, for safety's sake.
  13. by   beekee
    And let's not forget the nursing assistants. If we get these types of ratios, they'll cut the NAs and we'll be responsible for total care. With the acuity levels we see, that's neither safe nor reasonable.
  14. by   Been there,done that
    Quote from ICUman
    With all the expenses lost in replacing burnt out nurses, fines for hospital acquired pressure ulcers, medication errors, and everything else listed above, etc., how come hospitals haven't realized reducing nurse to patient ratios will actually *save* the hospital money?

    Is it more expensive really just to hire a few extra nurses? All the hospital scores and safety numbers would rise, including HCAHPS.

    It would be a win-win for everyone. What am I missing?
    The bean counters will not "just hire more nurses. "It cuts into the bottom line. Patients are expendable. Plenty more where they came from.

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