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Nurse : Patient Ratios and Patient Outcome
Transcript of Nurse : Patient Ratios and Patient Outcome
AND THEIR EFFECTS ON PATIENT OUTCOME
By Kristi Lunday As I worked a clinical shift in the emergency department, I noticed the nurse:patient ratio was 1:4. Each of 3 nurses was assigned 4 rooms. The triage nurse, usually the charge nurse, had no assigned rooms, but, helped out in all emergent, critical or trauma cases. I wondered how this number was set. Were they hospital recommendations? Emergency department standards? JCAHO minimum standards? Were the ratios set by the state? As I began my search for answers, I found that even though the nursing profession has been around for a long time, the controversy over what constitutes a ‘safe’ number of patients per nurse continues as a current topic in the United States and abroad. While it would be a logical jump in thought to assume that the lower the nurse:patient ratio, the better the patient care and outcome would be, does the evidence actually prove this as true? What does the Board of Nursing say is a safe ratio? The Texas Board of Nursing website states the BON has no authority over workplace or employment issues such as staffing ratios. (Texas Board of Nursing) Standards in Texas require nurses to maintain a safe environment for the patient, and to accept only those assignments within the education, training and experience they have. The Texas Nurses Association states that Texas hospitals are required to have a written nurse staffing policy to ensure an ‘adequate number and skill mix of nurses available to meet patient care needs. And to consider critical staffing factors such as number of admits/discharges/transfers, patient intensity and variability, scope of services provided, and nursing characteristics. (Texas Nurses Association, 2009) There is great debate between having mandatory nurse-patient ratios versus leaving those decisions up to the hospitals and nurse supervisors. The premise behind mandatory ratios is that the minimum, specific, guaranteed nurse staffing will produce better patient outcomes and alleviate nurse workloads and increase job satisfaction. (Tevington, 2011) An interesting piece of information I found was actually a copy of the bill that was passed in California. What are other states doing? This bill was the first and only one of its kind. A ground breaking piece of legislation that actually put hard, fast, measurable numbers on how many patients a nurse should be required to take care of during a shift. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased-in implementation beginning in 2004 and completed in 2008. (Chapman, 2009) Examples of the nurse:patient ratios stated in California law are: 1:1—trauma emergency unit, operating room, patient under sedation 1:2—CCU, NICU, emergency critical care, L/D, CCU, PACU, burn units 1:3—emergency units, step-down units, pediatrics, telemetry, antepartum,
combined L/D and postpartum units
1:4—med/surg, intermediate care nursery, psych, other specialty units 1:5—rehabilitation units, skilled nursing 1:6—well-baby nursery and postpartum—3 couplets (Boxer, 2011) Stipulated in SB 992 is that the ratios be met ‘at all times during a shift.’ The legal interpretation of this is that if a nurse takes a lunch break or goes to the restroom, another nurse who is at the maximum patient ratio, cannot cover the other nurse’s patients. This results in the hiring of extra nurses to cover for regular nurses anytime they take a break for any reason. During a regular 12 hour shift, a hospital is required to give a nurse 2 30 minute breaks. The first break is mandatory. The second break is optional and must be agreed upon by both the nurse and supervisor. It is feasible that each nurse would need coverage for 1 hour of each 12 hour shift. This required coverage has resulted in scheduled breaks, taking away the nurses ability to leave at the best time for the patient, not when the scheduled time arrives. As you can see, these 6 simple words have created a financially and politically charged atmosphere in meeting the stipulations of the law. In my research, I found many studies done on the result of ratios and patient outcome, but the measurements were not equivalent. Some measured outcome bases on RN’s on staff, some factored in LVN’s and floating staff, as well as travelling nurses. Some also factored in such specifics as reductions in pneumonia, pressure ulcers, or mortality. I will do my best to summarize the information I gathered, though, it is sometimes not equivalent information. It is estimated that between 22,000 and 49,000 thousand patients die in hospitals each year because of errors in the delivery of care. (Lucero, 2009) In a review of studies published in 2008, the overall incidence of in-hospital adverse events was 9.2%, with 43.5% of those incidents being considered preventable, 7.2% of which led to death of a patient. (Lucero, 2009) Not having enough time to complete nursing tasks is stated as a major problem of nurses nationwide. A study in 2004 examined the association between tasks left undone and the quality of care. There was a strong relationship between the number of tasks left undone and the quality of nursing care. According to a report in the National Consumers League, 45% of people questioned felt that their safety or family member’s safety was compromised by a lack of available nurses. One-third indicated that medications were not received in a timely fashion and they did not receive adequate information about care before discharge. (Schmalenberg, 2009) The Hospital Quality Alliance routinely evaluates quality of care data on patients with acute MI, heart failure and pneumonia. According to data from HQA and JCAHO, only 75.9% of patients hospitalized with MI, HF, PNM received recommended care. Hospitals with more technology and higher RN staffing had higher performance on all of the process care measures. (Lucero, 2009) Minimum nurse-patient ratios may help nurses reach their goals in having time to complete the nursing tasks required for their patients. Increased RN staffing has been associated with an increase in patient safety, quality of care and patient satisfaction, as well as a decrease in patient length of stay and nurse burnout and turnover. (Douglas, 2010) It is associated with a reduction in hospital-related mortality and patient adverse events related to health care. (Shamliyan, 2009) Each additional RN per patient per day is associated with a 4% decrease in the odds of death, fewer failures to rescue, reduced length of stay and fewer cases of hospital-acquired PNM. (Griffiths, 2009) Great conflict arises, however, when the cost of care increases, not decreases. While the analysis of data suggests that increasing nurse staffing could provide public savings from avoided patient deaths and adverse events, hospital business is different. It appears that the cost of increased staffing of hospitals still increases the cost for the hospitals, despite better patient care. This will be a subject of some debate over the next few years as more and specific studies are done to balance out the two sides of the coin. Research support for adequate staffing and balanced workloads of nurses as essential to achieve good patient, nurse, and financial outcomes, has led 17 stated to introduce mandatory nurse-patient ratio legislation. (Unruh, 2008) However, the most powerful stakeholders and lobbyists for the profession of nursing are the American Nurses Association and the American Hospital Association, which are both opposed to mandatory nurse-patient ratios. (Rajecki, 2009) The Registered Nurse Safe Staffing Act of 2009 (S.54) is a possible solution. It allows nurses to be involved actively in the unit based staffing plans, and holds hospitals accountable for proper implementation. (American Nurses Association ANA, 2010) In this manner, nurse experience and education have been positively related to clinical outcomes and reduced mortality. (Meyer, 2009) This kind of thinking gives back the autonomy nurses love while involving them in their own job safety and satisfaction. The American Nurses Association states “Mandatory staffing plan legislation may be linked with the most positive nurse work environment perceptions when compared with implementation of mandatory staffing ratios or no workforce regulation.” Texas legislators and nurses are also weighing in on the issue of ratios and their effects on patient care. In 2010, nearly 2000 registered nurses at five Texas hospitals voted to join the National Nurses Organizing Committee-Texas, an affiliate of National Nurses United. NNU represents 160,000 nurses nationally and is the fastest growing union by far in the nation and the state. (PR Newswire, 2011) It appears that this organization is on the side of mandatory maximum nurse:patient ratios. This goes against the Texas Nurses Association who agrees with the ANA. The question does not seem to be if nurse:patient ratios are needed or if they improve patient care or patient outcome. The question seems only how to arrive at such ratios and what are considered acceptable, safe ratios. Where does this leave a new graduate nurse? A very scary place. While the information I was able to find had advantages to both sides, enforcement of hospitals to actually follow the policy will be required. On many nurse blogs online, nurses commonly were stating they were required to attend to 12-15 patients on a daily basis. They were definitely on the side of mandatory ratios to protect them and their patients. Others were working for hospitals that had taken on an interactive role with their nurses to provide workable numbers and had developed a staffing plan with their nurses to protect the patients. It would definitely be to my and other graduate nurse’s advantage to ask about nurse:patient ratio policy and ensure we would want to work in the environment of that particular hospital. One that values the skill set of their nurses, focuses on staff and patient safety, as well as working toward improved patient outcome.