Study: Nurse staffing ratio hasn't improved patient care

allnurses Guide · Apr 5, 2008

I do have the article.

I'm also reading "Safety in Numbers: Nurse to patient Ratios and the Future of Healthcare" by Suzanne Gordon, John Buchanan, and Tanya Bretherton.

Later I'll post.

oramar · Apr 5, 2008

What actually is going on out there. My experience is that if I took care of 8 patients with an aide and a secretary it was doable. If I found myself taking care of 5 all alone with no assistance I was much more swamped. If they are increasing number of RNs and getting rid of support staff it is a waste of time.

oldiebutgoodie, RN · Apr 5, 2008

Well, I have several comments. The Association of California Nurse Leaders, who were part of the sponsorship of the study, are nurse managers. Here is their membership criteria from their website:

"Regular membership is available to registered nurses who: have responsibility for leadership of the patient care process in any setting manage financial and human resources in health care settings direct appropriate allocation and utilization of human resources provide education and/or consultation to health care providers or consumers of health care provide health care in an advanced and/or independent practice role design, conduct or evaluate research conduct accreditation/licensing surveys publish, edit, or author a health care or business publication provide leadership in the regulatory, nonprofit or legal environment hold an appointed or elected public office "

They are not exactly an unbiased group.

Secondly, we have to ask whether pressure ulcers and falls are measures of nursing quality? Is this a reliable measurement? Perhaps their PCTs are understaffed.

Pressure ulcers are often unavoidable. In my hospital, we get so many debilitated, malnourished, either underweight or obese, with poor mobility, elderly, incontinent, etc. Unless the nurses wave a magic wand, pressure ulcers are going to develop, unfortunately.

I can't really comment any more until I have read the study, but methinks I smell a rat. I can see nurse managers all over the country jacking up the patient load now, citing this study.

Let's not forget Linda Aiken's excellent study on mortality rates and patient ratios. Here's the link:

http://jama.ama-assn.org/cgi/content/abstract/288/16/1987?ijkey=f0e84fe6dda0d52b71f906390e23c1ba21a56d61&keytype2=tf_ipsecsha

Skeptically,

Oldiebutgoodie

allnurses Guide · Apr 6, 2008

What actually is going on out there. My experience is that if I took care of 8 patients with an aide and a secretary it was doable. If I found myself taking care of 5 all alone with no assistance I was much more swamped. If they are increasing number of RNs and getting rid of support staff it is a waste of time.

If they are doing that (and some are) it is illegal.

Hospitals "conveniently forget" that the regulation states,

"Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. "

And:

"Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care "

http://www.dhs.ca.gov/lnc/pubnotice/NTPR/R-37-01_Regulation_Text.pdf

http://www.dhs.ca.gov/lnc/NTP/default.htm

In other words they try to violate the law. On some units they get away with it.

Look what the Sutter nurses are doing just to get their hospitals to obey the law.

Even so it is an improvement on the supreme flexibility they had before to staff however they pleased.

Some were OK and others so very dangerous.

forrester · Apr 8, 2008

I too will have to read the study.

We have to remember that our own leadership is not to be trusted, so any "studies" that come out against the ratio laws need to be received sceptically.

We can also expect severe frontal assaults on CNA/NNOC, as they begin to intimidate large groups.

Politics plays hardball.

RN Power Ohio · Apr 8, 2008

There are many flaws in the data collection related to the staffing lab that is California. There is large dispute over what the nursing sensitive indicators are per Sean Clarke.

In addition, the final phase in of the ratio did not happen until January of this year. It will be at least 2 years before an accurate study is complete- and even then we cannot trust it because of the question of appropriate indicators.

AHA and ANA are in control of CALNOC data and they oppose ratio's - seeking any study that will discredit common sense.

There is a recent study from Sean Clarke that shows that work condition has improved significantly for nurses.

If we examine the data from Victoria, Australia- ratio's do improve outcomes!

RN Power Ohio · Apr 8, 2008

Per Suzanne Gordon in her recent speech in Cleveland on her new book-"Ratio's are not the fix all for the nursing crisis but they are however, a fundamental prerequisite for change".

I believe you will find this sentiment re-iterated in her book Safety In Numbers.

lindarn · Apr 8, 2008

What actually is going on out there. My experience is that if I took care of 8 patients with an aide and a secretary it was doable. If I found myself taking care of 5 all alone with no assistance I was much more swamped. If they are increasing number of RNs and getting rid of support staff it is a waste of time.

They are getting rid of support staff because they know that any patient assignment will be difficult without them. They want to set you up to fail to "prove" that staffing ratios don't improve patient outcomes. What better way to prevent staffing ratios from being implemented in other states but "prove" through "studies" that more nurses taking care of fewer patients (and more expensive to hospitals- $$$) don't do what they set out to do. California is being watched by nurses and hospitals all over the country over the staffing ratios. If ratios "fail" in California, (i.e. don't improve patient outcomes), then nurses trying to implement ratios in other states, will fail in their attempt. That is the agenda of cutting support staff.

JMHO, and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

allnurses Guide · Apr 8, 2008

in the first paragraph of the regulations is this sentence, "staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system."

from the final statement of reasons:

"in order to clarify that a hospital cannot reduce overall staffing by assigning licensed nurses to duties customarily and appropriately performed by unlicensed staff, it is stated that staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

at 22 ccr 70053.2 and 70217(b), the pcs is defined as a system that is established to determine the amount of nursing care needed by each unit, on each shift, and for each level of licensed and unlicensed staff. setting a minimum level of staffing for licensed nurses is not intended to alter the current requirement of the pcs to determine needed staffing levels for licensed and unlicensed staff. "

ratio page: http://www.dhs.ca.gov/lnc/ntp/default.htm

ratio regulations hospitals are required to follow as a condition of their licensure: http://www.dhs.ca.gov/lnc/pubnotice/ntpr/r-37-01_regulation_text.pdf

faq: http://www.dhs.ca.gov/lnc/pubnotice/ntpr/r-37-01_faq2182004.pdf

statement of reasons: http://www.dhs.ca.gov/lnc/pubnotice/ntpr/r-37-01_fsor.pdf

santhony44, MSN, RN, NP · Apr 8, 2008

I haven't read the studies, but I wonder about a couple of things. Someone else mentioned one: what is the condition of the patients upon admission? Are they already malnourished, immobile, incontinent, etc.? Did the study look at the condition of each patient's skin upon admission and exclude those who already had signs of ulcer formation, not to mention those with frank ulcers?

Also, is there a high percentage of high fall risk patients in the studies?

Well, I suppose there would be the support staff issue, too, a third thing.

Saying that improving staffing hasn't improved patient care just seems to defy common sense, which reminds me of the old saying:

figures don't lie, but liars can figure.

forrester · Apr 9, 2008

They are getting rid of support staff because they know that any patient assignment will be difficult without them. They want to set you up to fail to "prove" that staffing ratios don't improve patient outcomes. What better way to prevent staffing ratios from being implemented in other states but "prove" through "studies" that more nurses taking care of fewer patients (and more expensive to hospitals- $$$) don't do what they set out to do. California is being watched by nurses and hospitals all over the country over the staffing ratios. If ratios "fail" in California, (i.e. don't improve patient outcomes), then nurses trying to implement ratios in other states, will fail in their attempt. That is the agenda of cutting support staff.
JMHO, and my NY $0.02.
Lindarn, RN, BSN, CCRN
Spokane, Washington

Very formidable opposiotion:

California Hospital Association

American Hospital Association

Most, if not all, hospital corporations

California Association of Nurse Executives (Chapter of AHA)

American Association of Nurse Executives

Most, if not all, hospital administrations and their affiliate organizations

Have I left anyone out?

Oh yes, maybe competing unions too, since they want to see CNA/NNOC fail.

Let's make sure the data is collected by, and evaluated by, academics without associaiton ties. We need good data interpreted well.

NNOC needs to stay on top of who is evaluating the data and releasing reports. Good to be proactive with this stuff.

Study: Nurse staffing ratio hasn't improved patient care

the first study of the effect of nurse-to-patient ratios on care in california hospitals concludes hospitals have hired more registered nurses, but they've had little effect on two areas of care -- patient falls and bed sores.