Patient Outcomes Related to Nurse Staffing Nurse to Patient Ratio

Staffing in Nursing

Staffing and Other Nursing Issues

The main topic of this paper is staffing related to the field of nursing, here it is very important to realize a correct balance between the demand of nurses and available nurses at any medical facility. Since the duty of any medical professional like a doctor requires much assistance from a subordinate such as nurse therefore it is vital for any organization to fulfill this requirement in a way that best suits all parties involved especially the patients. This paper will focus on many different aspects related to the issues of staffing and will also shed some light on some of the difficulties of keeping a low or high number of required nurses.

The emphasis here would also be on many different aspects related to staffing such as the economical perspective, the quality perspective of any medical organization and so on. The paper is divided into three main sections, in the first section the focus would be given on introduction as well as some of the negative aspects of patient outcomes or care due to insufficient nurse staffing, this would also look at the losses that the medical organization may suffer from because of these mentioned aspects. The second section will identify much of the positive aspects related to the outcomes with sufficient nurse staffing, this may include some of the benefits as well which the medical organization could attain if it maintains the appropriate level of nursing standards in itself.

Finally, the third section will address the Californian law related to patient or nurse ratio alongside the conclusion page which will summarize all of the information that we have discussed in the paper and would also give the reader an idea regarding the overall importance safety of patients in the field of healthcare.

1.2 Negative aspects related to irregular staffing and other facts

Hospitals currently in the United States are under extreme pressure to control the overall cost of its medical care while improving patient health outcomes at the same time especially with respect to a proper reduction in medical errors that might be damaging for some cases or even fatal for others. These and many more concerns including irregular staffing are on the agenda of the top decision makers of hospitals. Intuitively, anyone would expect that a higher ratio of nurses associated with patients could lead towards better patient outcomes and if this is correct then various patient benefits must be deemed as an important consideration in the overall determination of levels of nurse staffing.

It is ideal for hospitals to make their decisions regarding nurse staffing guided by proper empirical evidence, here different studies have properly examined this issue and by analyzing some of the data from more than one hundred and fifty hospitals in the state of Pennsylvania, it was determined that a cross-sectional variation related to nurse staffing levels is correlated negatively with the patient morality, this is measured as risk adjusted thirty day failure and mortality to the rescue rates.

Another analysis of different sorts of administrative data from more than seven hundred and fifty hospitals in eleven states that took over an year span concluded in finding out higher levels of staffing of nurses being directly associated with lower than average failure to rescue rates, this analysis also reported better patient outcomes alongside a variety of different specific facts such as reduction in upper gastrointestinal bleeding, rates related to urinary tract infection, cardiac arrest, pneumonia and shock cases at hospitals.

The regression analysis in the above mentioned cases gave important evidence related to cross-sectional correlations, but there are still some concerns that remain about casual relationships in all of these mentioned cases. With regard to this, there are many potential problems, two of which are as follows. The first is related to a specific type of omitted variable bias. "There is a relative amount of variation across various hospitals at the level of resources which are devoted to patient care" (Cimiotti, 2012).

The mentioned variation exists at primarily the nurse staffing but it is also found at different other aspects such as the quality and quantity of medical equipment, the proper adoption of educational efforts in order to keep the current medical staff on best practices, the efficiency related to the management practices and so on. The cross-sectional regression analysis attempts to take control of the mentioned factors but the researches in this regard have a very limited set of covariates in the beginning to work with. Therefore it is easy to assume that those hospitals which possess a relatively higher level of nursing staff also have above average level of various different positive and negative factors that are associated with patient care. Cross-sectional regression analysis tends to state the effect of high patient or nurse ratio on the health outcomes of patients.

Second problem is related with endogenous sorting. Generally it is expected that medical providers would devote relatively high resources towards patients who are statistically much more likely to show the highest effect for that attention, this includes those patients as well who are at much greater risk with regards to the adverse outcomes. Example here includes the expectation of high mortality rates on those medical units which have high nurse or patient ratios.

A researcher could attempt to take control over the severity of the medical conditions of patients but this practice is extremely difficult to do considering what is available as data. Here, the researchers would usually underestimate the vital beneficial impact related to higher nurse-to-patient ratios at the patient outcomes. Concerns somewhat related to these belong to the evaluations which are based upon hospital-level paned data, therefore the hospitals which experience improved and better nurse staffing levels may well be increasing their resources alongside other factors which are unobserved. Converse to this, those hospitals which increase their levels of nurse staffing may well be doing that because of an increase in the levels of their patient's general acuity levels which might also show signs of improvement in the overall health of patients.

An appropriate response towards these mentioned concerns is for researchers to do a search for shifts to nurse staffing that are exogenous and then use that variation for the exploration of the affect on patient outcomes. Though true exogenous variation might not be available for this procedure but there are various other ways to figure out the so called natural experiments for the purpose of generating plausibly exogenous changes at the nurse-per-patient ratios.

A good example here is related to the identification strategy, which is used to utilize natural variation that occurs at hospital admissions, this in turn create variations at patient loads. Using this approach, it is found out that those patients who are admitted when their patient load is high have a greater mortality, but effects are calculated to be relatively small and therefore are not significant statistically in different specifications.

It is acknowledged that the mentioned interpretation is very difficult since it has no independent data which deals on how hospitals might deal with situations where a sudden influx of patients occurs, therefore if the hospitals respond by providing overtime shifts to its nursing staff then the ratio of nurse to patient might not change much in case where there is any sort of surge in the hospital for admissions.

This paper will also provide an analysis which exploits a sort of exogenous shock for the nurse staffing so that the relationship between patient outcomes and nurse staffing is studied in more detail, here the California Assembly bill 394 will also be analyzed which mandated the optimum amount of patients per nurse at any given hospital setting. When this law was passed, some of the hospitals had the appropriate staffing figures as related to nursing whereas others did not have their nurse staffing according to the mandated standards proposed by the bill. Therefore changes in staffing ratios at the hospitals from pre-mandate to post mandate time is partially because of this legislation.

Here are some of the other facts associated with nurse to patient ratios, according to federal law the nurse to patient ratio at any given health facility should be 1:1 at the main operating room, at intensive care, neonatal intensive care units, critical care, labor and delivery units and at post-anesthesia recovery departments it should be 1:2, at general medical-surgical units it should be 1:5. The main factor which makes the law hard and controversial to implement for hospitals is that it requires those facilities to be in a state of continuous compliance with the ratios.

This means that the amount of patients designated to each nurse must not exceed the ratio during any given time interval of the nurse' duty or any of its shift. This also means that if the nurse has to take a break for the restroom then even in that scenario it has to reassign its patient to any other nurse available on duty at that time. Since the year 2004, eleven states which are namely Nevada, Maine, Illinois, Connecticut, Oregon, Ohio, New Jersey, Nevada, Washington, Vermont, Texas and Rhode Island alongside District of Columbia have adopted regulations or enacted legislation that addresses nurse staffing although many of them chose less rigid approaches as compared to the California law.

After some five years of the placement of California law, nurses were very optimistic regarding their ratios. According to an analyst, the ratio law was a success and it was commonly witnessed that there was an increment in the total amount of RNs licensed in the state of California after the implementation of the law, also there was a decrement in the rate of turnover because of a gain in patient satisfaction towards the hospital management. The law also improved patient safety greatly as well as saved the lives of many patients, made nurses to be a much stronger advocate for their respective patient and also towards the overall career of nursing.

Hospitals, though are not yet convinced especially since there exists no conclusive evidence regarding if the ratios have really reduced errors or improved care. A study in this regard suggested that if a nurse is to be designated to more than for patients at the same time then the risk of fatality towards the patients goes up by seven percent for every additional patient involved.

This means that if the risk for fatality for every patient goes up seven percent when a single nurse is looking after five patients at the same time then it goes to forty two percent for every patient when that same nurse is looking after ten patients at the same time. This shows the extreme amount of risks involved in the field of nursing and also that if a single nurse is dedicated towards more than its respective share of work then it is bound to do more mistakes than usual and some of these might result as fatal for the patients.

Common mishaps related to the nurses when they are assigned more patients at the same time include giving the wrong medicine to the patient, this sort of action could worsen the condition of the patient greatly and could determine if it will live or die, also the nurses might not be present for the patient in times of emergency when the patient needs help, this could also be a fatal error from the side of nurses and can be easily the cause of death for the patient.

Some other mishaps done by the nurses are as follows, the patient may fall very easily since it requires getting up on its own for restroom and if the nurse is not there for help. "Nurses are commonly known to reply to the patients that they don't want to bother them just so they can avoid their duty of service" (Blegen, 2011).

It is recommended that checking on the patient must be done every hour during daytime and after every two hours during night, If the nurse asks the patient if it wants to go to the restroom or if it makes sure that the television remote or tissues are within the reach of the patient then this simple factor could reduce the amount of patient falls by fifty percent.

This is the reason many of the hospitals have implemented the concept of hourly rounding. According to data some thirty percent decrease was recorded in patient falls inside two months at various different hospitals after the implementation of hourly rounding at the oncology and medical surgical unit. Some hospitals even recorded a sixty five percent decrement in fall rate mainly due to the rounding done by nurses at regular intervals.

Spread of infections is also a vital mishap which could be done on behalf of the nurse who is assigned more duty than what it is supposed to handle, this error is also very common in overcrowded hospitals and were the nurses often don't bother taking proper care of the patients therefore it is regarded as one of the major negative factors which can be associated with shortage of nurses at any given hospital or medical centre.

Here, hand hygiene is very important for the prevention of infectious diseases, as a guideline nurses must disinfect all of the equipment as well as other important items at their disposal in order to ensure that there is no spread of disease. Nurses are also told to wear proper personal protective equipment during surgery or when performing patient care, this practice is even more important to perform when the nurse is operating on a patient who is diagnosed with any fatal virus or disease such as HIV.

There are various different best-practices interventions that can be applied by nurses so that they can reduce the chances of any spread in infection at the hospital, this includes keeping appropriate hand hygiene, usage of chlorhexidine for the purpose of skin preparation and so on.

The nurses should also ensure that full barrier precautions are done and a proper sterile field is maintained at insertion. In order to prevent pneumonia, nurses should always keep the bed's head elevated and do daily oral care by using chlorexidine. According to various clinicians, a better success rate in regards to safety can be achieved if the nurses on duty could identify hazardous elements on the spot and properly address those risks so that they may not infect anyone in its premises.

On their behalf, the nurses should also take more time in assisting their subordinates so that they can properly learn from their experiences, this could greatly benefit the new recruits in the field of nursing and could also help them handle tough situations in a rather easy manner. Nurses should also give guidelines to their apprentices on how to handle more than one patient at the same time and what are the important techniques and tips that may save lives at critical moments. It is commonly found that the gravest of problems arise from the simplest of mistakes on behalf of the nurses or doctors and therefore it is very important for all the medical personnel to be good in their basics and learn to identify the problem early on before it is exaggerated to a certain level.

For nurses, it is very important to be properly dressed, used sterilized equipments, give proper time to their patients, be more helpful not only to their subordinates but to their respective seniors, be vigilant in case of any outbreak, emergency or any other catastrophic event and this is why so much importance is given to them at all levels in the hospital.

2. Positive aspects of proper nurse staffing

Proper staffing results in a broad reduction in the relative risks of mortality related with hospital treatment as well as more attention towards every individual patient. According to a research relative to the field of nursing, by adding one RN FTE per patient a hospital eliminated sixteen percent of its patient related deaths. By properly examining patient and workload occupancy at large and prominent urban hospitals, various researchers concluded that even a little increment in the nurse-to-patient ratio could lead towards an increased rate in patient adverse events. This study found out that just a 0.1% increase could lead towards a twenty eight percent increment in the adverse events. The main conclusion here also pointed out that hospitals must initiate different processes in order to avoid operating during over capacity in order to decline adverse patient outcomes.

A survey concluded that the nurses reporting greater workloads are much more likely to show more frequent medical errors during their practice and the count of patient falls is also increased as compared to their previous years when their workload was low therefore if the concept of timesharing is introduced in the working environment for nurses then it could greatly help every person involved. Timesharing differs from work shifts as the nurse could easily take a break during its work time and appoint a subordinate or a colleague for the care of the patient on a temporary basis. Researches also suggests that the patients are often more prone to fatal circumstances when the nurse is out on a break even for five minutes, therefore proper appliance of timesharing could result in the saving of many lives.

It is also important for a nurse to properly state the amount of working hours it can dedicate to its field of work, for those hospitals which gave this option to its working staff showed a better result in the performances of its nurses alongside a better record of patient care. It has been statistically determined that the chances of making an error at a shift which is twelve hours long is as much as three times greater as compared to a shift which is about eight hours or less for the nurse. The institute of Medicine recommends that shifts for nurses should always be less than twelve hours during any twenty four hour time period whether voluntary or mandatory.

In many cases, it is even seen that the management of hospitals use different sorts of motivational factors in order to increase the morale of its staff, especially the low end workers which often include many nurses. The purpose here is to make them give their best to the organization where they work, the management can do this by offering many incentives related to work which includes bonuses that are associated with work efficiency. This may convince many of the nurses to work with more quality rather than more quantity.

The hospital management could also include the factors of choosing employees of the month or year based on their performance, this could support more competition at workplace and the result is often seen as a more dedicated and hard working staff which works not only for self-interest but for the patients as well as the organization where it serves giving all a better expression of themselves.

Motivational factors also provide benefits to the hospital as more and more nurses are willing to do voluntary duty for the sake of genuinely helping others, this could solve the key staffing problems often faced by hospitals. It could help the management implement a better work schedule for everyone as well as giving better advantages in terms of timesharing for its staff. "If the staffing is just appropriate enough to serve all the needs of the patients then the problem is just with maintenance rather than the overall management of resources" (Needleman, 2011).

Results from various different hospitals in the state of Pennsylvania suggested that an increment in staffing as proportional to the requirements of the patients or the influx of new arriving patients was associated with reduction in decubitus ulcers, atelectasis and urinary fall infections. The main reason here was that every nurse was finding proper space and time to look after the patient of its interest and this also resulted in more corporation among the nurses and better handling of emergency situations.

Proper staffing also helps the hospital in its economical aspects, although it is a common belief that more nurses would cost more to the hospital but the fact is that if staffing is done according to the proper requirements of the hospital then it is the most cost effective practice the institution could have. The reason for this is that fewer nurses could result in more fatal errors on behalf of the hospital which would result in giving the hospital a bad reputation, whereas if the hospital performs the practice of safe staffing appropriately then it can boast on its medical record and even charge some selective patients more based on the requirements related to their treatments.