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  1. SafetyNurse1968

    Just Say “NO” to Nurse Staffing Laws

    You’ve worked on a busy Med Surg unit for almost a year now. You were so excited to be hired right out of nursing school to the day shift, but it’s been so much harder than you ever thought it could, and so different from what you expected. It only took a few days to discover that no one does anything like they taught you in nursing school, there’s just no time. Recently you’ve been cringing every time your phone buzzes, worried it’s the nurse manager asking you to come in for an extra shift. It’s so hard to say no. You want to be a team player, but you’re just so tired. You’ve been wondering if you’re cut out to be a nurse, but maybe this is just how it is. Today is your fourth day in a row. You arrive on the unit to discover that not one, but two nurses have called in sick, and one of your nurses is a floater from labor and delivery. Normally you have five patients, but today you see with a sinking heart that you’ve been assigned seven. You sit at the computer next to your nursing mentor, trying to wrap your brain around your day, trying not to cry. He’s a good nurse and seems to notice everything. He turns to you and says, “Are you okay?” You point at the seven patients on your computer screen and reply, “How can this be safe? How can they do this to us…to our patients?” He says, “It’s a right to work state, and the hospital can do whatever they want.” You say in disbelief, “So there’s no law against this? There’s no maximum number of patients we can be assigned? They could give us twenty next time?” He shakes his head ruefully and says, “Medicare has guidelines for patient ratios, but this hospital has never followed them and we’re still running.” He looks over his shoulder before he turns back to you and says under his breath, “We shouldn’t talk about this at work, but there’s a group you can join to fight for safe staffing laws. Check it out when you get home, it’s called NursesTakeDC. It’s a dot org. But don’t talk about it here, you could get in big trouble.” Mandated Nurse-to-Patient Ratios Does this conversation seem familiar? Have you ever felt like you were working in unsafe conditions and wondered, “Isn’t there a better way?” As a patient safety specialist, I’ve always been a huge advocate for safe staffing laws as a solution to so many of the problems nurses face. But, then I read a recent article, Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care and I had to give my position a second look.1 How Can There be Controversy Over Something So ... Obvious? Opponents say ratio laws would exacerbate nursing shortages across the country, limit access to care, and take important staffing decisions out of the hands of nurses. Danny Chun is a spokesperson for the Illinois Health and Hospital Association (IHHA), a leading advocacy group for hospitals. He states that safe staffing laws are “a deeply flawed, inflexible, rigid approach to setting staffing levels that do not improve quality, safety or outcomes, but in fact would adversely affect patients.”1 The IHHA is against the Safe Patient Limits Act, a bill recently introduced in Illinois (House Bill 2604, Senate Bill 1908). Under the Safe Patient Limits Act, no nurse working in a hospital could be responsible for more than four patients at a time. The ratio would be even lower for special units like L&D, ICU and the ER. If passed, any facility that fails to comply could receive a fine of up to $25,000 per day. Critics of the bill say that the consequences could be catastrophic, causing shortages of nurses and money. There may be increased wait times for patients in the ER, and hospitals may have to turn away patients because they don’t have enough nurses to meet the ratios. In addition, an unexpected influx of patients due to epidemics, mass shootings or other disasters could make it impossible to meet the ratios. Small hospitals operating in regional areas could be forced out of business. Chun says in Illinois, “more than 40% of hospitals across the state are losing money or barely surviving.” The cost to the hospital could be passed on in the form of higher healthcare costs. The biggest criticism being offered is that mandated ratios don’t work. Chun says, “The evidence is not conclusive that ratios improved quality, safety or outcomes,”1 The Evidence Here is where I get excited. I went to Google Scholar and typed in “Safe Staffing Laws, nursing” and got 44,400 hits. I love digging into the research to find the truth (like the X-files, the truth is out there…) I found multiple review articles that speak to the state of the science on safe staffing ratios. One by Olley (2017) suggests that there is a significant research gap to support claims of increased patient safety in the acute hospital setting with improved ratios (for all the REST of the evidence, check out my Just say "YES" article on this topic).2 California is the only state in the union with a safe staffing law. AB 394 was passed back in 2004 after a massive effort by the California Nurses Union. The result of the bill is that nurses in California have approximately one less patient than the national average. Multiple studies have shown that the standard mortality rate decreased by more than 33% after the enactment of the bill.3 This seems like pretty good evidence…evidence that the law that California enacted is working in California. See where I am going here? The biggest criticism of bills in other states (and this comes from organizations like the American Nurses Association) is that there is no empirical evidence supporting specific ratio numbers. Passing legislation without sufficient evidence is potentially dangerous since legislation is difficult to change. Critics say the laws currently proposed also don’t take into account nurse education, skills, knowledge and years of experience. In Bill 394, only 50% of the mandated nurses must be RNs. Some say these laws ignore patient acuity, required treatments, length of stay, team dynamics, environmental limitations, variations in technology and availability of ancillary staff. And last but not least, these laws are inflexible and don’t allow for the changing needs of patients.4 The Bottom Line $$$ The mortality rate may have decreased, but the finances are problematic. To meet mandatory staffing ratios, hospitals in California have had to cut funding for supplies, upgrades and education and holding patients longer in the ER. The result is increased economic costs for employers, with the unanticipated side effect of an increased workload for nurses in non-patient tasks as ancillary staff are dismissed. 4 & 5 The PRO Side I’m not actually telling you to say “NO” to mandatory staffing laws. I want to get a conversation going, so please comment! To learn more about Nurses Take DC and what you can do to make a difference, take a look at my second article on the topic. Most importantly, before you speak up about safe staffing laws, make sure you are knowledgeable on the topic. We must be well educated on all sides of a topic if we want to weigh in on shaping the future of patient care. References Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals. Statewide and National Impact of California’s Staffing Law on Pediatric Cardiac Surgery Outcomes Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis Mandatory Nurse-Patient Ratios
  2. SafetyNurse1968

    Just Say “YES” to Nurse Staffing Laws

    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: Patient complexity, acuity or stability. Number of admissions, discharges and transfers. Professional nurses’ and other staff members’ skill levels and expertise. Physical space and layout of the nursing unit. Availability of technical support and other resources. 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, janet.haebler@ana.org, (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.

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