Nurse-To-Patient Ratios: Is it Important?

Nurse-to-Patient Ratios: Is it Important?

The climate and role of the acute care nurse has drastically changed over the last three decades. The rising costs of healthcare and diminishing coverage and reimbursements from health insurance carriers have prompted acute care facilities to cut costs and modify procedures to remain profitable and competitive. The largest expense of any for-profit organization is payroll. Unfortunately, staff reductions are typically included in cost cutting efforts by management. Nursing staff levels are often impacted the most in hospitals trying to decrease costs. Hospitals have reduced inpatient admissions to the most critical patients. Shorter lengths of stay and fewer complications after surgeries are attributable to improvements in surgical procedures and technology. These factors lead to higher concentrations of patients requiring acute care.

Introduction:

Nurse-to-patient ratios refers to the number of patients each nurse has to care for. A history of nurse staffing and patient outcomes dates as far back as a study by Moses and Mosteller (1968).

They found nurse staffing among the significant determinants of mortality (as cited in Aiken, 2005). Later, publicly available Medicare data for U.S. hospitals generated more studies on the factors related to mortality. (Shortell & Hughes, 1988; Hartz, Krakauer, & Kuhn 1989; Silber, Kennedy, & Even-Shoshan, 2000). Authors of these studies reported that nurse staffing was significantly related to mortality (as cited in Aiken, 2005). Aiken, Clarke, Sloane, Sochalski, and Silber (2002b) produced the first study to specifically quantify the impact of nurse-to-patient ratios on death rates.

Minimum staffing ratios represent the minimal amount of nurses required to care for the maximum number of patients, without compromising patient or nurse safety. Both the public and physicians rank nurse understaffing of hospitals as one of the most serious threats to patient safety (Blendon, DesRoches & Brodie, 2002). Patient safety experts are concerned whether or not inappropriate ratios lead to higher mortality rates and a variety of complications and adverse effects as well as higher patient stays at hospitals. Nurse safety advocates are beginning to question if there is an appropriate number of each type of staff member within a healthcare facility, and, if there isn't how does it impact job satisfaction and the ability of nursing staff to have adequate multidisciplinary interaction to improve quality of care.

One suggested solution to ensure safe and effective nurse staffing has been to mandate nurse staffing ratios. Currently, California has minimum nurse-to-patient ratios resulting from the passage of AB 394 in the states legislator which went into effect in 2004 (Spetz, 2004). However, California is the only state to do so, calling to question whether other states or the federal government ought to follow suit.

Quality of Care / Patient Safety

More than one-third of practicing physicians and 40% of the public say either they or a family member have experienced a medical error and 53% of the physicians and 65% of the public believe nurse understaffing is a factor in these errors (Kaiser Family Foundation/Agency for Healthcare Research and Quality/Harvard School of Public Health, 2004). Results of a Harris Poll revealed that more than half ofAmericans believe the quality of health care that people receive is affected "a great deal" by a shortage of nurses (Harris Poll, 1999).

Aiken, Clarke, Sloane, Sochalski, and Silber (2002b) estimated that 20,000 people die each year because they have checked into a hospital with overworked nurses. They reported that patients scheduled for routine surgeries run a 31% greater risk of dying if they are admitted to a hospital with a severe shortage of nurses. The risk of death increased by 7% for each additional patient cared for over four patients at a time.

According to Beth Piknick, president of the Massachusetts Nurses Association, "Make no mistake about it, every day in Massachusetts patients are suffering in pain; patients are being neglected; patients are falling; patients are experiencing preventable and costly complications simply because their nurse is not there when they need them to be there because he or she is struggling to meet the needs of too many other patients." (as cited in MNA, 2006)

Nurse Staffing / Skill Mix

According to Cahill (1995), skill mix is, "the proportion of staff qualifications, levels of confidence, abilities, knowledge, and experience that are necessary to achieve an agreed standard of care for a given level of demand" (as cited in Currie, Harvey, West, McKenna, & Keeney, 2005).

Acute care facilities try to maintain low costs and employ quality nurses. Within this statement is a double standard. How can we have quality nurses and cut costs at the same time? This is where the skill mix comes into play. In the skill mix, there are Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. If the lesser skilled staff free RNs they can be better able to perform their nursing duties and assessments. If acute care facilities can agree on an appropriate number of each type of staff member within the facility, they might be better able to accomplish safe patient outcomes while keeping costs down.

Determining nurse-to-patient ratios is a complex issue where one solution is not sufficient to cover all circumstances. The American Nurses Association assembled a panel of nursing and health professionals to research appropriate staffing levels. The panel developed the following Matrix for Staffing Decision-Making (Table 1) in three major areas.

Table 1. Matrix for Staffing Decision-Making

Matrix for Staffing Decision-Making

Items

Elements/Definitions

Patients

Patient characteristics and number of patients for whom care is being provided

Intensity of unit and care

Individual patient intensity; across the unit intensity (taking into account the heterogeneity of settings); variability of care; admissions, discharges and transfers; volume

Context

Architecture (geographic dispersion of patients, size and layout of individual patient rooms, arrangement of entire patient care unit(s), and so forth); technology (beepers, cellular phones, computers); same unit or cluster of patients

Expertise

Learning curve for individuals and groups of nurses; staff consistency, continuity and cohesion; cross-training; control of practice; involvement in quality improvement activities; professional expectations; preparation and experience

Source: American Nurses Association (2005), 2005 Principles for Nurse Staffing, Retrieved December 6, 2006 at http://www.nursingworld.org/readroom/stffprnc.htm

Nurse Safety / Job Dissatisfaction

While nurse safety is a big concern, its goal is mostly to decrease the workload so the nurse can effectively care for patients. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) reported that each additional patient assigned to a nurse was associated with a 23% increase in the odds of job burnout and a 15% increase in the possibility of job dissatisfaction. They also reported that 40% of hospital nurses experience burnout levels that surpass the average for health care workers and that higher nurse-to-patient ratios are directly attributed to elevated emotional exhaustion and job dissatisfaction among nurses. Their research results further indicate that nurses working in hospitals with higher ratios are more than twice more likely to experience job burnout and dissatisfaction than nurses at hospitals with the lowest ratios. Likewise, Sheward, Hunt, Hagen, Macleod and Ball (2005) found that high patient to nurse ratios were associated with increased risk of emotional exhaustion and dissatisfaction with current job. Nurses who continuously work overtime or work without adequate backup incur greater absenteeism and poorer health.