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EBP: nurse-patient ratio
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Patient-Nurse Ratio and patient outcomes
Julia Moretl
Sarah Magill
Cindy Yim
Bethany Gerdes
Rachel Wheeler
Introduction
Introduction
PICO: Do patients have a higher quality of care in a hospital with a lower patient-nurse ratio versus a higher patient-nurse ratio?
-Nebraska has no regulation addressing nurse staffing in hospitals.
-Currently, 14 states have nurse staffing laws in place.
-Staffing levels is a factor in 24% of 1609 sentinel events (Joint Commission, 2003)
-Benefits to lower ratios include:
- Medication errors
- Decreased patient mortality rates
- Decreased length of stay
- Decreased number of preventable events including falls and pressure ulcers
- Decreased nurse fatigue
Nebraska Medicine Staff Policy
-Staffing is not determined on nurse patient ratios alone
- Take into account patient census, acuity, anticipated admissions/dismissals, and the experience and skills of staff
-Unit Manager Responsible for Nurse Patient Ratios
-Goal of policy is to provide guidelines
Nebraska Medicine Staff Policy
Overall, the purpose is to “maximize operations by establishing uniform guidelines for the utilization of qualified and competent personnel to meet the nursing care needs of the patients (Nebraska Medicine, 2015).”
If unit census shifts, unit manager determines ratio based on the shift and the needs of other units.
Articles
Care left undone during nursing shifts: associations with workload and perceived quality of care
Care left undone during nursing shifts: associations wi...
Methods
- Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards and 46 general acute national health service hospitals in England.
- 5 section questionnaire over seven pages.
- 13 different care activities measured
Results
Results:
- 86% nurses reported on their last shift at least 1 of the 13 care activities listed had been missed.
- Average of 4 activities missed per shift
- Average number of patients per RN were 7.8 per day shift
- 8.8 per afternoon/evening shift
- 10.9 per night shift
- Worst staffed ratio 11.67 patients per RN found twice as likely to report inadequate patient care, when compared to best staffed at 6.14 per RN
Results
Article Conclusion
- More patients per RN equates to more care missed.
- No evidence that increasing support staff affect nursing perception of care given to patients.
- Attention should be paid to quality of practice environment as a potential lower cost approach to improve quality and efficiency of nursing.
Nurse staffing levels make a difference on patient outcomes:
A multisite study in Chinese hospitals
Nurse staffing levels make a difference on patient outcom...
Method
- Study led by School of Nursing at Sun Yat-sen University. 181 Chinese hospitals survey. 91 Level 3 hospitals and 90 level 2 hospitals.
- Inclusion criteria: patients stayed over 3 nights in the hospital, were conscious, and able to communicate. Nurses on the units were also sampled.
- 7,802 nurse surveys and 5,430 patient surveys were analyzed
(Zhu et al., 2012)
Results
-Over 60% of the unit surveys reported they did not meet the 4:1 patient ratio set by the government in 1978.
-35% of nurses reported adequate discharge was not accomplished.
-30% of nurses reported poor or fair nursing care.
-Two-fifths of nurses reported they were not confident about their patients’ self-care ability on discharge.
-Patients reported satisfaction with response to call button.
-Patients reported a high dissatisfaction of communication of medications
(Zhu et al., 2012)
Results
Conclusion
- Inadequate nurse staffing might result in missed, but necessary, nursing care and negative patient outcomes. Low patient-nurse ratio could be an effective strategy for improving patient outcomes.
(Zhu et al., 2012)
Hospital nursing, care quality, and patient satisfaction: Cross-sectional survey of nurses and patients in China and Europe
Hospital nursing, care quality, and patient satisfacti...
Methods
- Cross-sectional survey of 9688 nurses and 5786 patients in 181 Chinese hospitals to determine the association between variation in nurse workforce and quality and safety of patient care, nurse job satisfaction, and job-related burnout.
Results
- -Average workload was 6.8 patients per nurse per shift overall
- 7.9 patient-to-nurse on a medical-surgical floor
- 2.5 patient-to-nurse in the ICU
- 36% graded their hospital on low patient safety
- 29% described quality of care on their unit as fair or poor
- about 50% lacked confidence in management to resolve patient care problems or that the patient could manage own care at home when discharged
- Nurse-reported outcome tend to be poorer for Chinese nurses than European nurses
Conclusion
-Higher patient-to-nurse ratios were associated with poorer nurse outcomes and higher likelihood of nurses reporting poor or fair quality of care, but unrelated to patient outcomes
-Nursing contributes to better quality of care and more positive patient reports
- Improving patient-to-nurse ratios and moving to a more patient-centered organization of care holds promise for reducing patient safety hazards of nurse burnout and improving patient satisfaction.
Other Considerations
Other factors that lead to patient outcomes: nursing education and experience, the hospital environment, legal policies, and nurse’s satisfaction with career and pay.
Nursing Education
Higher education helps to improve patient outcomes:
Nursing Education
- builds well-rounded problem-solving skills and wider scope of nursing practice
- better understanding of social, cultural, political and economic aspects that impact patient’s (Villanova University, 2017)
Hospital environment
Hospital environment: staffing, nurse involvement, managerial commitment, quality of care, etc.
Hospital environment
- Best work environments have less burnout/dissatisfied nurses (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014).
- High ratios lead to poor work environment, quality of care and poor patient safety.
- Staffing: dependent on nurses shortage, geographic area of hospital, and cultural considerations on requested time of (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014).
- Managerial commitment: low confidence in your manager leaves patients vulnerable to improper care and bad quality outcomes (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014).
State and Federal Staffing Laws
- The Registered Nurse Safe Staffing Act, 2015:
- protect nurses and
- reduce risk of longer patient stays, increased infections, med errors, falls, and death.
- State laws: CA Bill 394 1:5 nurse-patient ratio
- Legislative Staffing Plans: admin and nurse staff determine staff plans and
- Public disclosure: states report staffing patterns to public (Tevington, 2011).
Nursing Satisfaction
Nursing Satisfaction: Engaged workers vs. satisfied workers.
Nursing Satisfaction
- 25% nurses vs 16% US working population are disengaged (Gallup, 2002)
- Disengaged nurses increase negative patient outcomes (Gallup, 2002).
Magnet Recognition Program
Magnet Recognition Program
Magnet Recognition Program
- Accredits the top healthcare facilities based on outcomes
- Rated indicators under organizational outcomes include: clinical indicators (# of patient falls, infections, etc.), patient-satisfaction, and nurse satisfaction (American Nurses Credentialing Center, 2011).
- Hospitals above benchmark receive Magnet Recognition.
Conclusion
- Appropriate nurse staffing is associated with improved patient outcomes (ANA, 2015)
- Optimal nurse staffing is essential to delivering high-quality, cost-effective care (ANA, 2015)
- Future research should include more objective data such as looking at patient mortality or sentinel events versus subjective data.
- Further research should also be done to compare the staffing needs in different care settings
References
American Nurses Association. (2015). Optimal nurse staffing to improve quality of care and patient outcomes: Executive summary. Avalere Health LLC, 1-5. Retrieved on July 9, 2017, from http://www.nursingworld.org/MainMenuCategories/PolicyAdvocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios/Optimal-Nurse-Staffing-ES-Sep15.pdf
Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2013). ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety, 23(2), 116-125. doi:10.1136/bmjqs-2012-001767
Fitzpatrick, J. J. (2003). Joint commission on accreditation of health care organizations white paper: Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Policy, Politics, & Nursing Practice, 4(1), 71-74. doi:10.1177/1527154402239458
Nebraska Medicine. (2015). Nursing scheduling and staffing of nursing personnel. Nursing Policy and Procedure Manual, 1-9.
You, L. M., Aiken, L. H., Sloane, D. M., Liu, K., He, G. P., Hu, Y., Jiang, X. L., Li, X. M., Liu, H. P., Shang, S. M., Kutney-Lee, A., & Sermeus, W. (2013). Hospital nursing, care quality, and patient satisfaction: Cross-sectional surveys of nurses and patients in hospitals in China and Europe. International Journal of Nursing Studies, 50(2), 154-161. http://dx.doi.org/10.1016/j.ijnurstu.2012.05.003
Zhu, X. W., You, L. M., Zheng, J., Liu, K., Fang, J. B., Hou, S. X., ... & Wu, Z. J. (2012). Nurse staffing levels make a difference on patient outcomes: A multisite study in Chinese hospitals. Journal of Nursing Scholarship, 44(3), 266-273.