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Staffing Ratios - How Do They Affect You?

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by lizstaub lizstaub (New) New

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I and a group of students from Rowan University in New Jersey have compiled this article in reference to nurse-to-patient ratios. How has this topic affected you? What does your state legislature say about it, if anything at all?

Staffing Ratios - How Do They Affect You?

New Jersey, along with fourteen other states and the District of Columbia have legislation or regulations that address nurse staffing. Registered nurses that are faced with a higher nurse to patient ratios are faced with a higher rate of burnout and job dissatisfaction. Patient-to-staff ratio s have potentially grave effects on the patients being served. These staffing ratios can have a negative effect on patient safety and ultimately patient mortality. Many health Care facilities are being affected by the growing need for more Registered Nurses on staff related to the increase in higher acuity of patients and the demand for shorter hospital stays.

The New Jersey Legislature found that changes in the health care delivery system now had higher acuity levels. Recent studies have shown that this can result in medical errors, patient infections and increased injuries to both patients and caregivers. New Jersey's Assembly, No. 2548, introduced February 21, 2012, regulates the minimum nursing to patient ratio that would be provided in hospitals, ambulatory surgery facilities and certain Department of Human Services facilities. At minimum, there would be one registered nurse for:

1) Every six medical/surgical patients (during the first year after the regulations are adopted)

2) Every five medical/surgical patients (following the first year of the adoption of the regulations)

3) Every four patients in a step-down unit

4) Every four patients in a telemetry unit

5) Every four patients in an intermediate care unit

6) Every four patients in an emergency department

7) Every two patients in a critical care service of an emergency department

😎 Every patient in a trauma unit

9) Every six patients in a behavioral health or psychiatric unit

10) Every two patients in a critical care unit

11) Every two patients in an intensive care unit

12) Every two patients in a neonatal unit

13) Every two patients in a burn unit

14) Every two post-anesthesia patients in a recovery or post-anesthesia care unit

15) Every two patients in a labor and delivery unit

16) Every four patients in a postpartum unit (where the mother and infant share the same room)

17) Every six patients in a mothers-only unit

18) Every four patients in a pediatric or intermediate care nursery unit

19) Every six well-baby nursery patients (State of New Jersey, 2012).

The bill also provides additional requirements including maintaining a float pool of qualified nurses to accommodate nursing needs and nurses assigned to a unit are to receive prior orientation and have demonstrated competency for that unit. The staffing system must meet the approval of the majority of the nurses in that unit or the nurses' bargaining unit. Furthermore, it establishes a system for nurses to file a complaint for violations (State of New Jersey, 2012). New Jersey does not require hospitals to establish nursing staff committees to meet patient needs and establish staffing policies (ANA, 2011). Four states also require that their staffing committee consists of at least fifty percent of nurses who provide direct care to patients. Two states take it one step further and provide evidence-based guidelines (ANA, 2011). The American Nurses Association advocates "a legislative model in which nurses are empowered to create staffing plans specific to each unit" (ANA, 2011) allowing for flexibility to allow for accountability of charges, the intensity of needs during the shift and the level of nursing experience of nursing staff (ANA, 2011). The state of Washington had proposed a bill that would require safe staffing plans as opposed to specific nursing to patient ratios (Welton, 2007).

Staffing ratios in the workplace affect the nursing staff, the patients, and the organization as a whole. "Researchers are examining the critical issues of how staffing, fatigue, stress, sleep deprivation, organizational culture, shifts work and other factors can lead to errors" (AHRQ, 2010). According to the Agency for Healthcare Research and Quality, having more patients per nurse puts the patient at risk for nursing care related adverse outcomes. These outcomes include UTIs, pneumonia, longer hospital stay, and even an increased mortality rate. As the ratio increases, the nurses' workload increases making them less able to attend to details or care for more critical patients in the amount of time they may require. Nurses surveyed by the AHRQ that had a nurse to patient ratio higher than recommended indicated job dissatisfaction in 40% of the nurses. These studies also found that only 33% of the nurses thought that there was enough staff on a daily basis to handle the workload they were presented with. One study by the AHRQ found that adding just one additional patient to each nurse on a surgical floor increased their likelihood of mortality by 7%. Increased staffing ratios impacts the nurse both physically and mentally. They are faced with more job dissatisfaction and increased risk of burnout.

When a patient is admitted into the hospital, they are there to receive medical and holistic care. According to a study of acute care hospitals in New Jersey, Pennsylvania, Florida and California, "There was a ten-percentage-point difference in the mean percentage of patients who would recommend the hospital between those cared for in hospitals with better nurse work environments (69.9%) than those cared for in hospitals with poor environments (59.6%)" (Kutney-Lee et al., 2009). Patient-to-staff ratios affect not only the nurses, who get over-worked and burnt out and thus their job performance suffers; it effects patients who are being cared for by these burnt out nurses, nurses who are not giving their 100% because they have too many patients, and too little time. Patient satisfaction is one of the most important factors to keeping a hospital running and by improving staffing levels, "may ultimately save hospitals money by preventing adverse events" (Kutney-Lee et al., 2009). By improving patient-to-staff ratios, it may cost more money, but will improve nurse and patient satisfaction. By adjusting the patient-to-staff ratio by just one patient, would impact the care received by the patient and thus would increase the likelihood of that patient receiving care from that hospital again. The nurses are not the only ones who feel that burn out, they are not the only ones affected. Hospitals must remember that they are in place to care for patients; at the end of the day the patient is the most important factor in a hospital.

The impact of total nursing staff to patient ratio in the hospital is significantly related to patient safety outcomes and in-hospital mortality. "Some private payers have followed the lead of the Centers for Medicare and Medicaid Services in no longer paying hospitals for the costs associated with certain nursing-sensitive, hospital-acquired "never" events, such as pressure ulcers and catheter-associated infections" (Buerhaus, Harris, Leibson, Needleman, Pankratz & Stevens, 2011). When nurses have a heavy workload the risks to patient's increase, as a nurses attention toward her patients becomes distracted and clouded by other mounting tasks. This situation is more likely to occur when there is inadequate staff per patient ratios, leaving less time for nurses to spend at the bedside performing direct patient care nursing assessments and interventions. According to Buerhaus, et al. (2011), better patient outcomes could be achieved by offering payment incentives as well as additional ongoing supportive resources for organizations that comply with suggested nurse to patient staffing ratios. A relationship has emerged between the level of in-hospital staffing by registered nurses and patient mortality, adverse patient outcomes and other quality measures. This evidence, proven in multiple studies cannot go unnoticed.

Studies have been conducted proving that patient safety is directly related to the quantity and experience of Registered Nurse on staff. These findings are the reason some states have proposed that there be mandatory minimum nurse-to-patient staffing ratio be enacted. These mandates are intended to address a growing concern that patients are being harmed by inadequate staffing related to increasing acuity and complexity of care (Welton 2007). Although these mandates may be beneficial to the patient there are some negative impacts on the facilities affected by them. The cost increases associated with need to higher more Registered Nurses to meet the minimum requirements for staffing ratios will not be offset by additional payments to the hospital, which will evidently result in mandates that are unfunded. In response to this problem hospitals are decreasing other staff, ultimately leading to the extra burden on the Registered Nurse to perform non-nursing duties. "The American Hospital Association (AHA), along with its individual member associations, have universally opposed laws mandating any specific nurse-to-patient staffing ratio. The AHA has argued that nurse-to-patient staffing ratios reduce scheduling and staffing flexibility. The American Organization of Nurse Executives also opposes mandatory ratios and has called for a more balanced approach through increased monitoring of nurse staffing, improved recruitment and retention approaches, and development of undergraduate nursing education" (Welton 2007). The lack of additional funding for increased Registered Nurse's on staff is the main reason why many health care facilities remain resistant and are fighting against proposed mandates to increase nurse-to-staff ratio's.

An alternative to implementing a minimum nursing to patient ratio is to change nursing from being a cost center to being a revenue center. Presently, nursing costs are designated to either routine floor care or intensive care cost centers. With being a revenue center, specific care and supplies would be billed to the patient. This would allow for reimbursement for the increased number of registered nurses needed to care for the patients. Medicare and other payers would reimburse the facilities for the actual care given rather than nursing being included at a set cost in the room and board (Welton, 2007). Billing for the actual hours of nursing care would also allow for a collection of data that could be used for a comparison of nursing care and trends and provide a consensus on safe working acuities. Additionally, the data could help set health care policies, assist in establishing rates for services and assist in implementing healthcare services research (Welton, 2007).

There are steps that nurses can take to help change this issue in their facility. Nurses can join their Union or facility committees that address the United States Congress, State legislation and their facility's policy making. Alternative options include forming committees to address or modify time consuming tasks such as the admission process of new patients (Buerhaus, 2009), or issues such as missing or delayed arrival of equipment and inconsistencies in communication. Orientation for new nurse graduates could provide strong critical thinking skills and strengthen complex decision making with rationale through mentoring by experienced registered nurses (Ebright, 2010). Nursing can encourage brain-storming at Unit meeting for supplemental ideas such as RN stacking. This skill develops with experience while remaining continuously informed of the surroundings. " Stacking is the invisible, decision-making work of RNs about the what, how, and when of delivering nursing care to an assigned group of patients" (Ebright 2010).

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ANA. (2011). Nurse staffing plans and ratios: Summary of approaches. Retrieved from


Buerhaus, P. (2009). Avoiding mandatory hospital nurse staffing ratios: An economic

commentary. Nursing Outlook, 57(2), 107-112. doi: http://dx.doi.org.ezproxy.rowan.edu/10.1016/j.outlook.2008.09.009

Buerhaus, P., Harris, M., Leibson, C.L., Needleman, J., Pankratz, V. S., & Stevens, S.R.

(2011). Nurse staffing and inpatient hospital mortality. The New England Journal of Medicine, 364, 1037-1045. doi: 10.1056/NEJMsa1001025

Ebright, P. (2010). The complex work of RNs: Implications for healthy work environments.

(15). Retrieved from www.nursingworld.org

Kutney-Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Neff,

D.F., & Aiken, L.H. (2009). Nursing: A key to patient satisfaction. Health Affairs, 28(4). Retrieved from http://content.healthaffairs.org/content/28/4/w669.full

State of New Jersey. (2012). Assembly, No. 2548 State of New Jersey 215th Legislature.

Retrieved from www.njleg.state.nj.us/2000/Bills/a3000/2548_i1.pdf

Welton, J. M. (2007). Mandatory hospital nurse to patient staffing ratios: time to take a different approach. The Online Journal of Issues in Nursing, 12(3). Retrieved from: http://dx.doi.org/10.3912/OJIN.vol12no3Man01

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HouTx has 35 years experience as a BSN, MSN, EdD and specializes in Critical Care, Education.

9,051 Posts; 45,175 Profile Views

We're not moving toward mandated ratios at this time, but have enacted recent legislation requiring more staff nurse input into staffing & analyzing clinical issues/incidents to determine whether staffing was a causative factor.

Beware the ratios - without specific safeguards, ancillary and support staff positions will be sacrificed to minimize impact on the labor budget. The outcome could be even worse because nurses have to assume all of those duties.

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Has there been any update on this proposed bill?

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