Minimum Staffing Ratio

Beverly Tennant, RN
New York City College of Technology
Professional Nursing
NUR 4130, SEC E748 (84527)
Professor Jose M. Hernandez, MS, BS, RN
November 03, 2013

Nurses today are face with providing more complex care to patients who are acutely ill and require continuous care to prevent poor outcome. Patient care staffing has been reduced drastically in hospitals, nursing homes and other healthcare facilities across the country. In recent years nurses have called for improvement in nursing staffing ratio, which would reflect the needs of the patients and give them adequate time to provide care. Many of our nurses continuously reported that low nurse staffing level in the work place is jeopardizing the quality of patient care and putting them at risk for losing their licenses, exposing them to injuries, and other health risk, such as been stressed and burned-out. Today, nursing responsibilities have increased greatly, and so have the level of nursing accountability and the complexity of patient care. Nurses are faced with caring for more critically ill patients who are in need of continuous monitoring, and careful assessment tailored to their conditions. When hospitals do not increase nursing staffing to meet demands for these increase level of patient care; omission of care and long term complications can occur, resulting in poor outcome for patients. A 2005-2006 business case report for reducing patient to nurse ratio found that reduced patient to nurse ratio are associated with lower patient mortality rate, fewer complications, fewer hospital-acquired infections and fewer medical errors (Nettleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). Adequate registered nurse-to-patient ratios have been indistinguishably linked to positive patient outcome and reduction in patient care costs in all healthcare settings.
In 2004, California became the first state to establish minimum staffing requirements in acute-care hospitals and nursing homes. As reported by Huston (2009), “The literature continues to support that increasing the numbers of registered nurse in the staffing mix leads to safer work place for nurses and a higher quality of care for patient” (p.165). Supporters of mandatory, nurse-to-patient staffing ratios usually point to research indicating an association between nurse workload and patient mortality and morbidity. Several studies have found a higher prevalence of infections, such as urinary tract infections, central line catheter-associated bloodstream infections, pneumonia, failure to rescue and cardiac arrest when nurse’s workloads are too high (Welton, 2007). Other studies found that higher registered nurse hours per patient were associated with lower nosocomial infection rates, decrease thrombosis and pulmonary complications in surgical patients (“The Literature on Nursing Staffing, Quality of Nursing Care, and Quality of Jobs”, 2006).
Further studies have asserted that for each additional patient added to a nurse work load; there was a 7% increase in the likelihood of patient dying under that nurses care (Agency for Healthcare Research and Quality [AHRQ], 2004). A study of more than 10,000 nurses and 230,000 patients conducted by (Aiken, Clarke, Sloane, Lake, & Cheney, 2008), determined that hospitals with higher patient-to-staff ratios, surgical patient had a greater probability of dying within thirty days of admission. They also experience greater odds of death following complications. This occurred because nurses who have an increase in patient-to nurse ratio have excessive workloads, resulting in little time for surveillance of their patients, to make early detection of changes in their health, and to intervene in a timely manner, particularly in patients undergoing complex treatments. It is estimated that more than 6,700 in-hospital patient deaths and overall 60,000 adverse outcomes could be avoided by raising the nursing staff (Huston, 2009). Staffing levels especially those related to workload, also appeared to be related occupational health issues, such as back injuries, needle stick injuries and burned out. Safe staffing improves nurse performance and increase job satisfaction; reduces emotional exhaustion, and turnover rates. There is growing evidence that better nursing staff ratios are associated with safer environment for patients, it also reduces patient mortality rates and the cost of patient care (“The Literature on Nursing Staffing Quality of Care, and quality of Jobs“, 2005). We will now explore evidence of the effects on nursing staff ratio in other settings as well.
A research study of 1,376 residences of 82 long-term care facilities concludes that patient in facilities with more direct registered nurse time (30-40 minutes per patient day) had fewer pressure ulcers, urinary tract infections, acute care hospitalizations, and less deterioration in ability to perform activities of daily living (Clarke & Donaldson, 2008). Majority of research shows that increase in nursing staff, more stable nursing staff, and less frequent turnover positively contribute to a variety of outcomes in nursing homes. Shin (2013), report indicated that more registered nurse staff hours were associated with better comfort and enjoyment and more license practical nurse staff hours were associated with better dignity. Additional studies also report greater levels of registered nurse care in the neonatal intensive care unit (NICU) using the primary care nursing model resulted in shorter length of hospital stay and shorter duration of mechanical ventilation, oxygen therapy and parenteral nutrition. As we all know premature infants are fragile and vulnerable patients whose survival is dependent upon careful monitoring and provision of expert nursing care. These infants are immature and they are at risk for a variety of health complications during their stay in the neonatal intensive unit, increase in the numbers of registered nurse can optimize health outcomes for these patients. In addition, the incidence of nosocomial infections in the neonatal intensive care unit was less for patients with higher percentages of direct care provided by the primary nurse, because the more direct care that the nurse provides to the infant, he or she will be better attune to non-verbal, behavioral changes in the infant and is able to take action to prevent long–term complications (Mefford & Alligood, 2011). The enactment of the minimum staffing ratio law in California raises many other concerns, such as cost of hiring additional nurses and if there were enough nursing staff to meet the increase in staffing guidelines.
According to Huston (2009), the cost of hiring additional nurses is costly and could divert resources away from patient care and other services. According to one report, the main weakness of the mandatory patient staffing ratio is that hospitals are required to increase the number of registered nurses without receiving any increase in reimbursement for patient care (Welton, 2007). Mandatory nurse-to patient ratio staffing may exacerbate, rather than correct the imbalance between patient needs and available nursing resources. Welton (2007), states in his article that If Medicare and other payers for healthcare directly reimburse hospitals for the actual nursing given an individual patient, rather than bundling this care within a fixed room and board cost, hospitals would benefit more from a more reasonable payment system and the charges for nursing care would be equivalent to the associated costs for individual patients. This lack of payment to hospitals create a strong disincentive for hospitals to increase staffing and this is cited as one of the primary reasons hospital associations are fighting these proposed laws (Welton,2007). For example an increase of just one hour of additional care by a registered nurse per day at forty dollars per hour would increase cost by four thousand dollars per day and over a million dollars annually for a medium-size hospital that has on average one hundred adult medical-surgical patients (Huston, 2009).
A longitudinal study incorporating hospital fixed effects found that increases in registered nurse staffing will increase hospital operating expenses, but no statistically significant changes in operating margins. On the other hand increases in nursing staffing may off set increase in hospital cost by avoiding adverse patient outcomes, reducing patient length of stay, and reducing law suits (Welton, 2007). To offset the increase in cost of complying with minimum staffing regulations it is reported that many hospitals might eliminate or reduce the use of unlicensed supportive staff to reduce the cost of hiring more registered nurse, thus placing additional burdens on the registered nurse, who would be forced to assume non-nursing care tasks. A substantial number of nurses in California reported decrease use of unlicensed personnel such as nurse’s aide, housekeeping and unit clerks. There is little evidence in research literature to show that having more unlicensed personnel in hospitals adversely affects patient outcomes (Aiken et al., 2008)
Finally, although there was a nursing shortage, California was able to attract several new nurses and part-time nurses into the workforce when the new law was enacted, due to improvement in the work environment. As per internet sources nurses from all over the country rushed to California for jobs when the new legislation was passed. In my opinion, minimum staffing ratio is needed to reduce the level of workload for nurses. We must recognize that nurses are dealing with patients who more chronically and acutely ill, requiring greater level of care. Despite the cost and many challenges in enacting minimum staffing ratio, I think the benefits for increase patient outcomes, economic outcomes, and both patient and family, and staff satisfaction are tremendous. The need for adequate staffing ratio is of great importance to enhance patient care outcome in any healthcare settings.

References
Agency for Healthcare Research and Quality (2004). State-Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction. Retrieved 10/27/2013, from http://www.innovations.ahrq.gov
Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of Hospital Care Environment on Patient Mortality and Nursing Outcomes. Journal of Nursing Administration, 38(5), 223-229.
Clarke, S. P., & Donaldson, N. E. (2008). Nurse Staffing and Patient Care Quality and Safety. Retrieved 11/9/2013, from http://www.ncbi.nlm.nih.gov/books/NBK2676
Huston, C. J. (2009). Mandatory Minimum Staffing Ratios: Are They Working? In Professional Issues in Nursing: Challenges & Opportunities (pp. 165-178). Philadelphia: Lippincott Williams & Wilkins.
Mefford, L. C., & Alligood, M. R. (2011). Evaluating nurse staff patterns and neonatal intensive care unit outcomes using Levine’s conservation model of nursing. Journal of Nursing Management, 19, 998-1011.
Needleman, J., Stewart, P., Zelevinsky, M., & Mattke, K. (2006). Nurse Staff in Hospitals: Is There Business Case for Quality. Health Affair, 25(1), 204-211.
Nettleman, J., Buerhaus, P., Stewart, M., Zelevinsky, K., & Mattke, K. (2006). Nurse Staffing in Hospitals: Is There a Business Case for Quality. Health Affairs, 25(1), 204-211.
Shin, J. H. (2013). Relationship between nursing staff and quality of life in nursing homes. Contemporary Nurse, 44(2), 133-143.
The Literature on Nursing Staffing, Quality of Nursing Care, and Quality of Jobs. (2006). Studies of Nursing Staffing and Patient Outcomes, 11-18.
Welton, J. M. (2007). Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach. The Online Journal of Issues in Nursing, 12(3)
The Literature on Nursing Staffing Quality of Care, and Quality of Jobs. (2005). Minimum Nurse Staffing Ratios in California Acute care Hospitals, 11-18.