I see this as a safety issue, safety for both nursing staff and patients. I have worked as an RN for 30 years in all types of staffing arrangements. The ones that worked the best included CNAs, unit clerks and licensed staff. When I started my nursing career, we worked as a team, one RN, one LPN and one or two CNAs and 17 patients. We all worked with all of the patients. This was a great way to teach also, my CNAs and LPNs worked with me and learned or at least observed how to do everything I was doing. There were many things they could both do that did not require an RN license.
For example, one night we had a new colectomy patient who needed frequent colostomy bag changes. I had some tricks up my sleeve that I taught my CNA when we first came on shift. Later in the shift, when I was stuck in a room starting an IV, my CNA was able to prevent a complete blowout of that bag with what I had taught her earlier. She never would have touched the bag before but felt confident enough to apply what she had learned. This was not a skilled or license only activity but something that saved my patient a lot of discomfort and embarrassment.
Then, in the late 80's, admin got the great idea to move to primary care nursing, it was all the rage back then. I believe it was simply because they thought they could save money. Primary care works well if everyone has backup to help when they need two people or when they are working with another patient. With a well staffed unit, we were able to take up to 10 patients, mom/baby pairs at night and feel like we did a great job. Admittedly, 10 patients on a med/surg unit would be too many. Lifting/turning a patient without two people is dangerous, for both staff and patients. A unit clerk can answer call lights and help patients feel they are not being ignored. That same clerk can prioritize or triage those calls and communicate urgent needs to staff that may be stuck in a room.
When support staff, CNAs, clerks, are removed from the patient care picture, patient satisfaction rates drop and staff retention drops. My last unit had me staffing the night shift alone with up to 5 patients PP, PostOp, each night. When I say alone, I mean ALONE. I was housekeeping, dietary, lab and nursing all in one. If I had a patient that needed labs drawn, I had to draw them myself and run the blood to the lab, on the other side of the hospital. I was cautioned that if I left the laundry basket in the hallway with dirty laundry in it once more, they would sanction me. The laundry chute was also far away from my unit. Dirty food trays had to be walked to the next unit over to deposit them. Garbage cans were always overflowing, they were small and would fill up with one chux, and had to be dumped outside in the dumpster. This was a 400+ bed, inner city hospital! The L/D nurses were supposed to come over and help if I ran into problems but I had no way to call them quickly and they were really deaf to my call lights. There were many a night that I would go over to ask for help, while running crazy, to find them watching TV in the lounge. Even after asking they would refuse. I typically never left until at least 2 hours after my shift ended because I needed to catch up on charting. This unit is dying, losing its patients to other, more satisfying hospitals. It is poorly laid out, making staff walk much farther than needed to access linens, supplies and patient rooms. Instead of revamping it for improved function Admin and owners decided it needed a new style so they put over a million dollars into paint, flooring and new art work. They also decided to offer salon services, a hairstyle or pedi, to their patients while they were in-patient so they took out the family lounge and put in a salon. At the same time, money was so tight that they couldn't shut down the halls that were being remodeled, we had to work around the painters, ladders and floor installers. Needless to say, we nurses were just shaking our heads and rolling our eyes.
This unit had a lot of personnel issues and I quit after only a few months. It was a toxic place to work. It was also the most unsafe of any facility I have worked in and where I felt the most at risk for being sued by a patient.