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In my Just Say "No" article, I listed the evidence from California against mandated nurse-to-patient ratios, the only state to have a safe staffing law. Despite a reduction in patient mortality, California hospitals are struggling with the cost burden of mandated ratios, and nurses are busier than ever, just not with direct patient care.
All you have to do is read the articles and comments posted on allnurses for a few minutes to confirm what you already suspect. We need some kind of change. A recent New York Times article reported on thousands of nurses on strike in California, Arizona, and Florida. They were striking for better patient care, improved working conditions and higher pay. Their No. 1 demand: better nurse-to-patient ratios. In a survey of nurses, only 20% felt staffing levels were safe.1
Rules and Regulations
Fourteen states currently have official regulations for staffing ratios: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA. Seven states require nurse-driven staffing committees: CT, IL, NV, OH, OR, TX, WA. California is the only state with a law that requires minimum nurse to patient ratios to be maintained at all times by unit. Massachusetts passed a law specific to the ICU that requires a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient. Minnesota requires a CNO or designee to develop a core staffing plan with input from other nurses, similar to Joint Commission standards. Five states require some form of disclosure and/or public reporting: IL, NJ, NY, RI, VT. New Mexico has asked stakeholders to recommend staffing standards to the legislature. The department of health will collect information about the hospitals that adopt recommended standards and report the cost of implementing oversight programs.2
Federal regulation 42CFR 482.23(b) requires with Medicare certification to "have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient." However, no figures are mandated. Each state determines how to meet the Medicare requirement.3
Illinois passed the Nurse Staffing by Patient Acuity Act in 2007. The Illinois Health and Hospital Association cites the law as sufficient for governing nurse staging. But the law isn’t enforceable. Though it requires a committee to be formed to make up staffing plans based on acuity, less than a third of respondents to a 2018 survey by Nurses Take DC said their hospital had a staffing committee. Of the hospitals that did, less than half include enough nurses, or committee recommendations weren’t followed.4
The Price of Nursing
I’m going to refute the argument that a shortage of nurses will cause hospitals to close units or limit services if mandatory ratios are enacted. At issue here is that there are plenty of nurses. In Arizona 37,000 licensed, active RNs are not currently working as nurses.5 Why is that? The issue isn’t that there aren’t enough nurses, the issue is how poorly nurses are treated. A survey in 2014 demonstrated that nearly 1 in 5 nurses leave the first job within a year, and 1 in 3 leave within the first two years.6
Nurse turnover costs hospitals a lot of money, so why wouldn’t they want to keep us happy? Because we are expensive. Nurses make up almost 40% of operating costs for healthcare facilities. Hospitals would prefer to find a less expensive way to improve patient outcomes.7
California paints a vivid picture of this problem. Critics of AB394 were concerned about its increased financial burden on hospitals, especially safety-net hospitals, to maintain a mandated ratio. Economists found that the mandated ratio resulted in financial pressure on hospitals and declining operating margins in CA hospitals compared with other states.8
Current Nurse-to-Patient Ratios
What is the national benchmark when it comes to nurse-patient staff ratios? Pinning down a specific number is hard to do, given the legal vagaries from state to state. California RN-to-Patient staffing ratios range anywhere from 1:2 in intensive/critical care, PACU and L&D, to 1:6 in postpartum women only, med surg and psychiatric.3
Aiken and colleagues found that in England, the average patient-to-nurse ratios for all hospitals was 8.6 but varied 5.6 patients-per-nurse to 11.5 patients per nurse. They found a similarly wide variation in patient-to-nurse ratios across hospitals in every country studied.9
The Evidence
In 2002, Aiken, Clarke, Sloane, Sochalski, and Silber found that adding an additional patient per nurse was associated with a 7%increase in the likelihood of dying within 30 days of admission and a 7% increase in death resulting from a complication.9
In 2007, Kane and colleagues conducted a meta-analysis of 28 studies. They found that increased RN staffing resulted in lower hospital mortality and adverse patient events. They hypothesized that patient and hospital characteristics, including the hospital commitment to quality care contributed to the causal pathway.10
In 2008, Aiken analyzed data from 10,184 nurses and 232,343 surgical patients in 168 Pennsylvania hospitals. When staffing ratios were optimized, nurses reported more positive job experiences and fewer concerns with care quality. Patients had significantly lower risks of death and failure to rescue in hospitals with better care environments.9
CMS began the Hospital Readmissions Reduction Program under the Affordable Care Act in 2012. At the time, researchers found that higher levels of RN staffing were associated with lower readmission rates.8
In a systematic review of 43 articles, Lang et al. (2013) showed better nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates and shorter hospital stays.11
In 2018, Driscoll et al looked at 35 studies in a metareview and found higher staffing levels associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and greater number of patients receiving percutaneous coronary intervention within 90 minutes. They looked at 175,755 patients from six studies and found that high nurse staffing levels decreased the risk of death in the hospital by 14%.12
Aiken has looked at patient outcomes in both California, which passed its ratio law in 1999, and Queensland, Australia, which passed one in 2015. She said the result for patients has been fewer complications, fewer infections, fewer injuries — and even lower mortality.9
The Solution
The American Nurses Association has a position statement on safe nurse staffing, stating, “We all agree that there should be safe staffing. Safe staffing is essential to patient and nurse satisfaction and for safe patient outcomes. What we need is evidence of what those safe staffing practices are. Eliminating unsafe practices will improve our healthcare system.” The ANA supports that appropriate staffing levels reduce mortality rates, length of patient stay, number of preventable events like falls and infections.7
The ANA states that fixed staffing levels are problematic. Staff levels should depend upon:
The ANA supports a legislative model in which nurses create flexible staffing plans for their unit. What is needed is greater nurse involvement.
Take action by writing Congress to support safe staffing.
Share your story about being an everyday advocate with Janet Haebler, Senior Associate Director, State Government Affairs, [email protected], (301-628-5111).
You may also be interested in The Safe Patient Limits Act (H.R. 2581/S. 1357). This bill is currently sitting with committees in the senate and house. The bill sets limits on the number of patients a nurse can be assigned, depending on the hospital unit. Any facility that fails to comply could be subject to a fine of up to $25,000 for each day it is out of compliance. The bill factors in a plan for acuity adjustments that need to be made for patients and staffing. The goal of Nurses Take DC is to get the legislation passed to the Senate and House of Representatives where they can be put up for a YES vote. For more information, click NURSESTAKEDC.1
REFERENCES
1. NursesTakeDC
2. Update on nursing staff ratios
3. The Importance of the Optimal Nurse-to-Patient Ratio
4. Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Tung, L. (Nov 29, 2019).
5. Nurses in Four States Strike to Push for Better Patient Care Ortiz, A. (Sept. 20, 2019).
6. Nearly 1-in-5 nurses leaves first job within a year, survey finds Becker’s Hospital Review (Sept 5, 2014).
7. American Nurses Association (n.d.). Nurse Staffing Crisis
8. Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis deCordova, P. B. & Riman, K. (2019).
9. Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T. & Cheney, T. (2018). Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. Journal of Nursing Administration, 38(5), 223-229.
10. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S. & Wilt, T. J. (2007). The Association of Registered Nurse Staffing Levels and Patient Outcomes. Medical Care, 45(12), 1195-1204.
11. Lang, T. A., Romano, P. S., Hodge, M., Kravitz, R. L. & Olsen, V. (2004). Nurse-Patient Ratios. The Journal of Nursing Administration, 34(7/8), 326-337.
12. Driscoll, A. et al. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6-22.
About SafetyNurse1968, BSN, MSN, PhD
Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school
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