Importance of Safe Staffing Ratios
Introduction
Nursing is considered one of the most trusted professions. It is pertinent to retain such an important status; despite not being an easy task. According to American Nurses Association, (2016) Code of Ethics for nurses, provision number three requires each nurse to advocate for, promote, protect rights of, and promote safety of patients. It commands nurses to promote health and wellness, and practice with high standard of care in a caring, empathetic, and compassionate manner. There are several factors in this wonderful profession that can be quite challenging in meeting the standards of provision number three. One such challenge is inadequate patient-to-nurse (RNTP) ratio/understaffing.
This topic has been debated and researched for many years. It’s a phenomenon that has plagued the nursing profession for many years and has had negative impact/adverse effects on patients, nurses, and institutions. To address this issue in California, Cook, Gaynor, Stephens, & Taylor, (2012) reported the AB394 Legislature was sanctioned in 1999, in which action was taken to implement maximum RNTP ratios for California state hospital.  According to Huston, (2017) such a mandate was enacted on January 1, 2004; however, only 13 states have directed attention to nurse staffing regulations as of 2015.  The author further states that to date, “California is the only state that stipulates in law, regulations for required minimum nurse-to-patient ratios to be maintained at all times by unit” (Huston, 2017 p.125).
Barriers/Limitations to Staffing Ratios
In spite of numerous studies conducted and proven that mandatory staffing ratios is needed to provide high quality care to improve patient and nursing outcomes, there are those who oppose the mandate. Duffin, (2014) disclose the most stated reason for such opposition is cost and opponents believe that mandating hospitals to set minimum ratios would cause more harm (financially) than good, further exhausting an already burdened healthcare system. In an analytic study conducted by Coffman, Seago, & Spetz, (2002) the authors determined that commencement of RNTP ratio mandate in California in 2004, would raise cost of nurse wages to $143,836 per hospital, per year. Once implemented, the mandated ratio on Rehab and Med-Surg units would surge to $217,210 per hospital, per year. The authors further reckoned total year cost of implementing the mandate at 400 of California’s acute care hospitals will be $87 million.
According to Gee, (2015) safe staffing statute will add $1 billion per year to the cost of health care, while the mean cost for each hospital to comply is approximately $3 million to $5.3 million. Overfelt, (2005) reported within the first year of bill’s passage, eight hospitals in California closed and 85% were unable to meet ratio quota on each unit. It is evident that mandatory staffing ratios can be expensive, as there’s cost association in hiring and maintaining new nurses. Clark, Saade, Meyers, Frye, & Perlin, (2014) conducted a study to determine the correlation between RNTP staffing ratios and perinatal results of women who received Oxytocin during labor. Using a hypothetical universal 1:1staffing ratio for pregnant women necessitating such treatment, would require an extra 1,618 L&D nurse, which will lead to a total cost of $97 million per year. The authors deduced that by applying such data, the U.S. would stand in need of 27,000 L&D nurses, which will roughly cost the nation $1.6 billion annually. Based upon their findings, the researchers expressed disapproval of staffing mandate.
Another barrier to staffing mandate is it “do not address the very different levels of treatment complexity and nursing intensity among patients in a given unit” (Welton, 2007). Welton, (2007) further reveals no one patient is the same; the ratio statute mandates that each patient receives the exact same level of care, even if it’s not necessary. It doesn’t focus on patient needs or acuity level, and would treat each hospital unit as the same, despite difference in patient case mix. Welton, Unruh, & Halloran, (2006) conducted a study of 65 acute community hospitals and 9 academic medical centers in Massachusetts. Data was collected and retrieved from Massachusetts Hospital Association (MHA) Patient First data base, where the researchers viewed the state’s nurse staffing ratios and other pertinent data for 601 inpatient nursing wards for 2005. Each patient received constant nursing care during hospitalization; the quantity of care provided to each patient differed by medical treatment intricacy and other factors. It was found that staffing ratios for medical centers differed from community hospitals. The authors concluded that mandatory ratios must be avoided. “The difference in these variables between community hospitals and medical centers is expected due to greater severity of illness and increased complexity of care at the tertiary care hospital”(Welton, Unruh, & Halloran, 2006, p. 424).
The nursing shortage is another argument that may be used to oppose mandatory staffing ratio. In order to execute such a mandate, a surplus of registered nurses is required; however, with the nationwide nursing shortage, where would hospitals obtain such a large quantity of nurses? Coffman, Seago, & Spetz, (2002) concluded that RNTP staffing ratio does not guarantee that a supply of registered nurses will proliferate. The authors shared that hospitals in Australia experienced a huge influx of nurses returning to the profession, once staffing ratios were implemented in institutions. Yet, the nursing shortage continued as enough nurses did not return in order to satisfy the demand.
Literature Review on Benefits of Mandatory Staffing Ratios
Numerous studies have been conducted illustrating the association between staffing ratios and patient outcomes; with patient safety as the focus. Weissman et al., (2007) conducted a study with the objective to ascertain the correlation between hospital workload and Adverse Events (AE). The authors examined charts of 6,800 patients admitted to four hospitals, and concluded AEs were highly associated with inadequate RNTP. Clemens et al., (2008) reported transmission rate of health-care acquired infections (HAIs), such as methicillin-resistant staphylococcus aureus (MRSA) is increased during periods when hospitals are understaffed, including ICU and Neonatal units. Moreover, the authors indicated the success of controlling such outbreaks was associated with staff workload. Person et al., (2004) conducted a study to discern if staffing ratios affected in-hospital mortality, independent of patient treatment and patient and hospital attributes for patients with acute myocardial infarction. The study revealed greater R.N. staffing is liked to lower mortality.
Numbers matter greatly. Duffin, (2014) reported on a study where researchers scrutinized medical records of 40,000 ICU patients in England. Researchers inferred that an additional seven lives would be saved if nurse numbers per bed were to increase from four to six. Therefore, maintaining adequate nurse staffing improves patient survival rates. Nurses are at the forefront of patient care, with implementation of safe staffing, one has more time to dedicate to each patient, can detect early signs of adverse events, and quickly intervene to reverse effects of complications.
Upholding patient safety is the goal of every institution. Aiken, Clarke, Sloane, Sochalski, & Silber, (2002) led a study investigating the relationship between RNTP ratio, patient mortality, and failure-to-rescue (death as a result of complications) using data from 168 hospitals in Pennsylvania. The investigators divulged that for each extra patient assigned to a nurse, the chance of such patient dying within 30 days of admission is increased by 7%. Additionally, researchers found inadequate staffing increased failure-to-rescue chances by 7%. Another study implemented by Needleman, Buerhas, Mattke, Stewart, & Zelevinsky, (2002) used data from 799 hospitals in 11 states. Researchers found incessant positive correlation between increased nurse staffing and lower rates of potentially fatal complications such as pneumonia, shock, cardiac arrest, sepsis, and deep vein thrombosis.
Another study conducted by Aiken et al., (2010) compared a hospital in California with a hospital in Pennsylvania and New Jersey. The California hospital was found to have better patient outcomes (lower mortality rates) as compared to hospitals in the two other states, as a result of the mandated nurse staffing law. Furthermore, Kutney-Lee et al., (2009) reported staffing ratios markedly correlated with higher patient satisfaction and increased likelihood of patients recommending the hospital to others. In essence, by improving nurses’ workload, patient experience and quality of care can be enhanced greatly.
Inadequate staffing doesn’t only impact patients, but affects nurses in a grave manner where one feels negative towards one’s job. Tellez, (2012) informs continuous exposure to unsafe and harsh working conditions can lead to job dissatisfaction, burn out, and may cause one to contemplate quitting the job and/or the profession altogether. Aiken, Clarke, Sloane, Sochalski, & Silber, (2002) found that nurses working in hospitals with insufficient staffing are twice as likely to experience job related burnout and dissatisfaction compared to nurses in hospitals where ratios are adequate.  Vahey, Aiken, Sloane, Clarke, & Vargas, (2004) explored 20 urban hospitals in the U.S and concluded that increased nurse workload, due to understaffing, leads to burn out, feeling dissatisfied with the job and emotionally exhausted,  and having feelings of low personal accomplishments. Additionally, researchers found that more than one third of nurses had intentions to quit, and patient satisfaction on such units was decreased.
According to American Nurses Association, (2009), in 2008 ANA conducted an online poll where over 15,000 respondents participated. More than half reported intent to leave direct care nursing position, and 42% cited inadequate staffing as the reason. In addition to performing nursing duties, roughly two thirds reported having to perform non-nursing tasks such as delivering meals. Additionally, one third of respondents verbalized knowing a colleague who left bedside nursing due to unsafe staffing. Moreover, over half of respondents stated quality of care on their unit had declined. Approximately half would object to having a loved one receive care in the institution where they work, and almost one quarter reported contemplating leaving the profession altogether. Result of the poll is indicative that measures must be taken to improve dissatisfaction level that direct care nurses experience.
According to a study conducted by Tellez, (2012) the author explored the effect of the passage of California’s AB394 Law. The researcher revealed substantial increase in nursing and job satisfaction as the years passed. Such result is suggestive that staffing ratio law is associated with improved job satisfaction. Similarly, Aiken et al., (2010) found that as California nurses cared for fewer patients than nurses in other states (without staffing mandate), nurse burn out decreased, job satisfaction increased, and better quality of care was reported by nurses. Such outcomes, once again, display that numbers do matter greatly.
Inadequate staffing, job dissatisfaction, burn out, and decreased quality of care can be quite costly to institutions, resulting in negative outcomes. “For organizations, burnout can be costly leading to increased employee tardiness, absenteeism, turnover, decreased performance, and difficulty in recruiting and retaining staff” (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). Jones & Gates (2007) indicate nurse turnover is costly and price ranges between $22,000 to $64,000 per U.S. nurse. Punke, (2016) estimated that the cost of losing bedside nurse is roughly $4.9 million to $7.6 million. In another study, Jones, (2005) revealed the cost of turnover for four hospitals participating in the study cost the institutions $62,100 to $67,000 per R.N. and total nurse turnover cost roughly $5.9 million to $6.4 million.
Overwhelmed, emotionally and physically exhausted health care providers are more prone to commit medical errors. Andel, Davidow, Hollander, & Moreno, (2012) projected that medical errors cost the U.S. $19.5 billion in 2008, with numbers increasing to $735 billion to $980 billion (almost $1 trillion). Authors concluded medical errors and their corresponding cost can be decreased easily with implementation of improved policies and practices, Such as safer RNTP staffing ratios. Hence, such application can save institutions a great deal of money in the long run.
Understaffing contributes to nurses’ inability to provide patients with adequate discharge teaching/instructions, which can increase hospital readmission rates. Jencks, Williams, & Coleman, (2009) reveal estimated cost of readmission in the United States has surpassed $17 billion per year. Weiss, Yakusheva, & Bobay, (2011) conducted a study and established that adequate nurse staffing is cost effective, as it decreases post discharge utilization services by reducing readmissions within 30 days post discharge.  The authors also stated that improving RNTP ratio for the units in the study resulted in an annual net cost saving of $11.64 million. Thus, by providing more nurses, patients will be better prepared and educated prior to discharge, reducing readmission rate and cost. Finally, even though increasing R.N. staffing would be costly, Patterson, (2011) disclose that improved overall patient outcomes can offset the cost; for example, by reducing inpatient stays, recruitment and retention would certainly improve. In the long run, this can reduce the cost of high R.N. turnover rates.
Registered Nurse Safe Staffing Act
American Nurses Association (ANA) report, that The registered Nurse Safe Staffing Act is a proposed bill introduced in April 2015, with intention to protect patients. ANA states the act mandates Medicare-participating hospitals to form staffing committee of at least 55% nurses providing direct patient care, to develop nurse staffing plans, specific to each unit. The bill seeks to develop and implement unit-by-unit nurse staffing plans to provide patient safety, avoid preventable medical errors and hospital readmissions, improve nurse retention, and requires disclosure of staffing levels to general public. ANA reports that to date, only 14 states California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington have adopted a form of this bill in hospital regulation. However, California is the only state that indicates in law a set minimum nurse-to-patient ratio to be implemented at all times per unit.
Nurse Reinvestment Act & American Recovery and Reinvestment Act
According to Spiegel, (2012) Federal Government has also attempted to aid in implementation of mandatory ratios by enacting Nurse Reinvestment Act (NRA) and American Recovery and Reinvestment Act (ARRA). American Nurses Association informs President George W. Bush passed the bill on August 2002, and Congress provided $20 million towards implementing the act in 2003. As per Spiegel (2002), the bill provides nursing school scholarships to those who agree to work full time, for two years, at a hospital experiencing severe nursing shortage. The author shares that the bill also expands Federal loan nurse forgiveness programs. NRA aids institutions in attempting to meet staffing ratios by providing financial aid/scholarships to nurses, provide grants for advertising campaigns to encourage individuals to join the profession, retain nurses via career ladder programs, career counseling, and mentoring.
According to Alexandre & Glazer, (2009), Congress approved ARRA in 2009. The government passed the act to further help solve the nursing shortage problem. The researchers reveal ARRA contributes funds necessary to improve nursing workforce by providing more money to support education of new nursing educators, supply scholarships and loan repayment to nursing students, and promote diversity in the profession via loans and scholarships extended to minorities and those of low socio economic status.
Conclusion
Countless studies have been conducted by opponents and proponents of mandatory RNTP ratios. In my opinion, enough has been done to prove that such a mandate does help save lives of patients, improve patient and nurse outcomes, decrease job burnout and turnover, and save institutions money in the long run. Although barriers to implement this mandate exist, there are certainly ways of getting around such obstacles. Hiring additional nurses is costly, but the cost of adverse events and readmissions, and to replace skilled experienced nurses, has a greater financial impact on hospitals budget. Everyone involved in this public health issue, such as nurses, hospital administration, government, and professional nursing organizations, must come together to brainstorm on how to implement safe staffing acts that will benefit the nation.
References
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