Nurse to Patient Staff Ratios

How do we get it right/How does it impact Healthcare Costs

“I think your patient is dead!”

I was in the middle of admitting my 13th patient for the evening on a hectic medical surgical ortho neuro hospital unit, when I heard that phrase. The patient transport guy was standing in the doorway of my 13th patient uttering those words. He had come to transport one of my patients to the step down unit. And yes, the patient was dead!

Having 13 patients was not common. The most I had up to this point, 12. Code blues on the unit were a nightly occurrence. I remember thinking nursing school had never prepared me to take care of thirteen patients! Was this normal?

This memory popped into my mind on November 6, 2018 as the Massachusetts nurse ratio ballot was stricken down. The Massachusetts’ measure would have required hospitals to have one emergency room nurse for every one to five patients, with new mothers and newborns receiving one-on-one attention. Medical and surgical nurses would have a maximum of four patients while psychiatric nurses would be limited to five. Each violation would carry a $25,000 fine per day for the employer.

California Nurse Patient Ratio Laws

My experience occurred way back in 1997 in California. I was a new grad RN with only six months of nursing experience working on an ortho neuro med surg unit. In those days, having eight to ten patients per nurse was “normal.”

California’s law was approved in 1999 but did not take effect until about five years later. California was the first state to implement nurse to patient ratios in acute care hospitals and as of 2011, 14 other states have enacted some type of regulation related to nurse staffing level and 17 states have introduced legislation mandating minimum nurse ratios. State health officials developed the specific nurse-to-patient ratios over time, with input from different stakeholders. Some would speculate that passing this law would be easy, especially when a patient’s mortality is on the line. In fact, it did meet with lots of resistance since hospitals now had to hire new nurses, which would skyrocket costs.

How can it be safe for one nurse taking care of 13 patients? It’s not. At least, not from my personal experience. Thankfully, the laws were changed and today, in California the Med Surg Nursing ratio is one nurse per five patients.

Safety Explained Through Research

Research from Linda H. Aiken, a professor at University of Pennsylvania, has shown links between California’s nurse staffing law and better patient outcomes. Among her most cited work is a 2010 paper that compared the workload of nurses in California to nurses in Pennsylvania and New Jersey, which don’t set nurse-to-patient ratios. The study found that ratios in California were associated with lower mortality rates.

Another study in 2017 published in the Annals of Intensive Care found that higher nurse staffing ratios were tied to decreased survival likelihood. The analysis of 845 patients found that patients were 95 percent more likely to survive when nurses followed a hospital-mandated patient-nurse ratio.

Studies are not limited to the United States but are global. The BMJ safety journal 2018 longitudinal retrospective study found Lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.

Higher staffing ratios equals’ higher patient mortality, greater job satisfaction, and decreased nurse job turnover. When California initially passed its Nurse patient ratio mandate, it was feared that hospitals would higher lower skilled nurses, therefore lowering the quality of care. A study by McHugh et al in 2011, found this not to be true.

Aikin also published a study in 2002 where she found that in hospitals with high nurse patient ratios surgical patients experienced higher risk for mortality. Nurses were found to experience greater burn out.

The Agency for Healthcare Research and Quality (AHRQ) has also acknowledged the link between nurse staffing ratios and patient safety.

“Nurses’ vigilance at the bedside is essential to their ability to ensure patient safety,” AHRQ says on its website. “It is logical, therefore, that assigning increasing numbers of patients eventually compromises nurses’ ability to provide safe care. Several seminal studies have demonstrated the link between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity, and even mortality as the number of patients per nurse increases.”

Higher Costs, Few Savings

Media headlines boast “Higher Costs, Few Savings” when it comes to discussing nurse staffing ratios. But how can we place a ‘price’ on a human life? Critics of the mandated ratios, including the American Hospital Association and American Organization of Nursing Executives, claimed that the mandated staffing laws would financially strain providers, particularly small community hospitals. It would also make staffing and scheduling more rigid, which could hurt morale, they said.

Even Pamela Cipriano president of the American Nurses Association is quoted as saying in a statement “The rigid, one-size-fits-all approach proposed by the ballot initiative failed to acknowledge the complexities of staffing and undermined nurses’ professional autonomy and decision making in determining staffing on their units.”

There is much argument that with strict mandates there is steep fiscal costs and hospital administrators would not be able to have the authority to make changes. Jan Emerson-Shea, vice-president of external affairs for the California Hospital Association, seconds It’s impractical for any hospital to keep the ratio of nurses to patients within a set limit, she argues, with all the inevitable ups and downs of hospital life—a disaster or violent crime causing a sudden inrush of many patients needing urgent care, for instance, or a few nurses calling in sick on the same day.

Executive Michael Brookshire, a partner in consulting firm Bain & Co., states in an interview with Modern Health “There are ways to deliver very high quality care with lean staffing levels.” As evidenced by his profile on LinkedIn, Michael Brookshire is not a nurse. Nor does he have any experience working in a hospital. And I’m almost certain; he’s never read Linda H. Aiken’s extensive research on nurse staffing ratios.

Media headlines boast “Implementing mandated nurse-to-patient staffing ratios would cost Massachusetts providers an estimated $676 million to $949 million a year, net relatively minimal savings and have an insignificant impact on quality, according to a new analysis from the Massachusetts Health Policy Commission.” An independent state agency that monitors hospital spending stated that it would cost billions. Perhaps these headlines are what swayed voters away from passing safer staffing mandates.

Without ballot measures and mandated laws, how will hospitals be held accountable for following safe staffing guidelines? As it is, many nurses are afraid to speak up for fear of retaliation. How can it be guaranteed that if nurses do advocate for themselves and safe staffing for their patients that it will be heard if there is no law in place?

When a patient is admitted into a hospital setting, their mortality should not be at risk because of cost cutting due to nurse patient ratios. The only way we can get this right is to spend the money and add more nurses to the ratio.

Nurses should never be placed in a position that I was placed in when I was admitting my 13th patient. Nurses are pivotal in helping to pass nurse patient ratio laws since they are the ones taking care of the patients and not the executives. Nurses are the ones who hold the mortality of their patients in their hands. It is up to them to advocate and say, “This is not safe!”


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