Staffing ratios

[PHM]

Know this is a sore subject at many facilities, but why isn't there more discussion in nursing journals, papers, etc.?

We hear about various drug incidents, nurse negligence, malpractice, etc., how investigations revealed failures to follow protocol, nursing standards, etc (human errors in most cases, imho), and how nurses were disciplined/de-licensed/fired.

Is a ridiculously high nurse-patient ratio ever determined to be a causative factor?

I've been to staff briefings on employee satisfaction surveys where the employer cites pay and staff friendliness as major employee grievances, but they won't ever ever mention the NP ratio mismatch. Managers will then boldly ask why staff retention is so difficult. I've previously mentioned ratios as a (if not "the") major reason for both retention problems and/or the majority of "incidents" not only locally but probably nationally, and it's like talking to a vacuum.

Maybe I should become a medical malpractice ambulance chaser. I know I wouldn't waste much of my time poring over charts and documentation. I'd delineate the causative factors, cite the human error involved and then go straight at the throats of management for "negligence in proper staffing."

Anyone know of facilities in Florida (my only area of interest right now) where the NP ratio actually matters to employers???

Phil

[land64shark]

I'm a student doing my Peds clinicals at All Children's Hospital in St. Petersburg. I was very surprised to find that they have a max of 4:1 on the floors. It seems like a very pleasant place to work. Also, all new grads get a full 22 week orientation program for transition from student to competent nurse. (They've contracted with some special training outfit, Versant.) Can't beat that with a stick!

[NurseguyFL]

Phil,

This issue has been discussed extensively in many nursing journals, conferences, etc. It may not always appear that way though because of the way in which the issues are usually approached. Even among many so-called non-profit hospitals, management is accountable to an executive board for how money is being spent, and management usually attempts to qualify their 'success' in terms of how much $$$ they are able to save. Higher nurse/patient ratios is directly related to this because lower ratios translates to hiring more nurses to care for the same number of patients.

From a nursing point of view, lower ratios make perfect sense because we would have more time to give better quality care to each patient and it is also reasonable to expect that errors, stress, and turn-over would also decrease. However, we can't forget that healthcare is a business. The MBAs at the executive level who make all the decisions are FULLY aware of the quality issues; however, from their point of view, spending more money on nursing staff to care for the same number of patients is simply not good economics. There are certain 'laws' in economics that are based on the principle that productivity and profitability can always be increased if employees consistently work more efficiently and with fewer resources. This is the concept they are using to manage and evaluate the performance of nurses. It works well on a production line, where the processes are mechanical; but, its not difficult to see why it doesn't work in bedside patient care.

It should neither be a wonder nor a surprise to anyone to find that management will always seek to blame nurses for the issues you described. If they don't blame the nurses then they would have to blame themselves for poor management strategy, and that's not going to happen. At the end of the day, all that really matters to management is the bottom line.

[MT RN]

Very well said, NurseguyFL! I won't go into detail, but I had an incident with a pt. that had a very bad outcome shortly after I came off of orientation. This was on a very busy med-surg floor where I had 9 very heavy pts., and not nearly enough time to give anywhere near proper care.

In discussing the incident with my manager after it was over, I mentioned the fact that poor staffing was directly related to the outcome and the manager immediately went off on me, telling me that staffing had nothing to do with it, staffing is not a problem, etc. Of course she couldn't come up with any other reason either.

As NurseguyFL said though, all that matters to management is the bottom line, and as long as we keep working with short staffing and getting through our shifts without killing anyone, they don't really care.

[PHM]

I agree, and thanks Nurseguy for a great reply. Guess you could sense my frustration in the post.

I am, of course, aware the bottom line is all-important in business/management, but one would think that for the very reasons you cited (errors, stress, turnover) plus long-term litigation insurance and risk, etc a correction in the right direction would eventually take place. I also find it contradictory that management's annual bonuses are based on cost-savings . . which of course come from keeping ratios high. It almost make me laugh, as well, when leadership kicks out rhetoric wondering why nurses leave the profession early.

I like many, will probably opt out in the next year, or two. Sad to see a profession that on one hand is so rewarding places it's members at such high risk for lawsuits and associated health factors (stress, et al) all due to factors indirectly linked to something beyond their control.

Thanks for you inputs.

[linzz]

Hi PMH, I am from Canada. I am an LPN but I am just starting my BSN this fall in the bridge program and I agree with you 100 percent. This cost saving mentality sickens me. It is almost if the suits are providing healthcare with the help of an actuary who crunches the numbers to do a risk analysis of staffing ratios and law suits and if the numbers come up on the positive side for the hospital, then staffing ratios remain ridiculous. Of course they are not the ones who have to worry about a board of nursing yanking their licence or an unhappy patient launching a law suit blaming the poor nurse who ran their backside off their entire shift to keep up with an impossible workload. So yes, I too get annoyed when I hear about a nurse who is supposedly doing a bad job, now I wonder or should I say know that it probably wasn't the fault of the nurse. Maybe if I was younger I would also become an ambulance chaser. For now I will drive my car with my black ribbon which here in Canada is ONA's (our Ontario RN union) symbol for all the nurses who have left the profession due to frustration.

[Tweety, BSN, RN]

It's well documented that the lower the ratio the safer the patients and the happier the nurses.

When they look at incidents that harm patients. They look at the incident in an isolated manner - the nurse didn't follow the five rights, or whatever process caused a bad outcome. Unfortunately they don't look at the ratio.

The Florida Board of Nursing is notoriously known for not caring about ratios when reviewing sentinel events that have a nurses license on the line. They'll ask questions like "did you use the chain of command", "if the assignment was unsafe why did you accept the assignment". They don't all high ratios as a reason for making mistakes.

It would be nice if the BON reversed this strategy and began holding the facilities more accountable for events that occur due to poor staffing and ratios.

[linzz]

I was surfing the net looking for a camp to send my child to this summer and there was one that actually was advertising low child to caregiver ratios. Too bad our Canadian health system can't accomplish this.