How Are Safe Nurse-Patient Ratios Determined?
One of the most significant variables tied to healthcare quality is patient safety. According tothe Institute of Medicine (IOM) patient safety is “indistinguishable from the delivery of quality health care patient safety” (Hughes, 2008). There has also been a shift in how we perceive our control over medical errors. We now long accept that healthcare related errors are inevitable consequence of being hospitalized and acknowledge that there are human factors that are strong predictors in preventing errors. Sherwood and Barnsteiner state “Nurses are in the forefront of examining the work environment to identify quality and safety issues and the influence of human factors, the interrelationship between people, technology, and the environment in which they work” (Sherwood and Barnsteiner, 2017, p. 8). One suggested method to improve safety and patient outcomes is through establishing safe nurse-patient ratios. Although there is literature that supports better nurse staffing levels, there is some debate about whether mandated staffing ratios is an effective and necessary method to address staffing. Other debates also exist about any measureable impact on patient outcomes and whether it can be directly correlated with nurse staffing levels. While there is agreement about the value of adequate nurse staffing levels in improving patient safety, there continues to be discussion about how determine a safe staffing level that not only protects the patient, but also addresses concerns from both bedside nurses and administrators.
- Literature Review
All of the articles included in the research are associated with nurse-patient ratios, patient
safety, and the impact of mandated staffing levels. The databases used for this research were from the Shapiro Library at Southern New Hampshire University and include CINAHL, MEDLINE, AND Nursing Journals on Ovid. Keywords used in the literature search were nurse staffing, nurse-patient ratios, patient safety, and mandated nurse staffing. Search results were limited to “peer-reviewed journals and “electronic full text” and included publications in the past five years.
In the article “Unfinished nursing care, missed care and implicitly rationed care: State of
the science review”, the authors conducted a literature review of the factors associated with unfinished nursing care. Based on the literature reviewed, the authors stated, “Predictors of unfinished care influenced perceived team interactions, adequacy of resources, safety climate and nurse staffing” (Jones, Hamilton, Murry, 2015). The article emphasized the importance of adequate nurse staffing to address time scarcity and unfinished nursing care that may increase adverse event in hospitals.
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Another study “Predictors of Excess Heart Failure Readmissions Implications for Nursing Practice” compared standards of nursing care and patient outcomes for hospitals in Massachusetts, which have no limits on nurses’ patient assignments, and California, where a law has mandated nurse-patient limits for over a decade. In reviewing both states for readmission rates associated with heart failure, the authors concluded that Massachusetts had higher rates of readmission (Stamp, Flanagan, Gregas, Shindul-Rothschild, 2014).
The cohort study “Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study” examined the impact of high nurse workload and its relationship with the probability of hospital survival. The article concluded that patients exposed to a high workload/nurse ratio during their ICU stay had lower risk-adjusted odds of survival (Lee, et al., 2017).
The article “The association between nurse staffing and omissions in nursing care: A systematic review” reviewed quantitative studies to investigate the association between staffing and missed care. The authors stated that low staffing levels are associated with missed nursing care. Although missed care can be an indicator of adequate nurse staffing, the study acknowledged that staffing is not the only indicator that can be attributed to missed care. “It seems that although staffing levels may have an association with the rate of reported missed care, most missed care cannot be attributed to low staffing” (Griffiths, et al., 2018).
Another article related to this issue was “Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations”. This is a retrospective cohort study to assess whether legislation in Massachusetts for ICU nurse staffing was associated with improvements in patient outcomes (Law, Stevens, Hohmann, Walkey, 2018). The authors concluded that state mandated nurse-patient staffing ratios in ICUs did not affect improvements in patient mortality or other complications. The mandate did not have a significant effect on nurse staffing and the authors suggest that state mandates may not be the most effective means of improving patient outcomes.
- Drawing Connections
Although there is literature that discusses the impact of adequate nurse staffing and the
impact on patient safety and outcomes, there are also articles that counter the actual impact on mandated nurse-patient ratios that can be presented in an accurate and measurable way. There are several studies that show that nurses are concerned with missed patient care due to time constraints, which is tied to inadequate staffing. Jones, Hamilton, and Murry state “Time scarcity among bedside nurses is the primary driver of unfinished care which is associated with multiple negative outcomes for patients, nurses and organizations…It is important that nurse managers develop effective staffing and teamwork strategies to reduce unfinished care” (Jones, Hamilton, and Murry, 2015). However, because categories of unfinished care were self-reported and based on qualitative studies the authors caution that “the strength of evidence does not support causal inferences” (Jones, Hamilton, and Murry, 2015).
In another study examining readmission rates for patients with heart failure, the authors compared data between Massachusetts, which has no limit on nurse patient assignments, and California, which has a mandate in place for over a decade. The study found an association between nurse staffing in Massachusetts and a higher rate of readmission for heart failure” (Stamp, Flanagan, Gregas, Shindul-Rothschild, 2014).
In addition, a cohort study looking at the risk of mortality in critically ill patients and the effects of staffing ratios concluded that “as little as one day of high workload/staffing ratios is associated with a substantially increased risk of death in critically ill patients” (Lee, et al., 2017).
On the other hand, there is also literature that argues for more data and research and contends that current research does not adequately prove the correlation between mandated staffing and patient outcomes. In a study looking at nurse staffing and omissions of care, the authors state “While the association between staffing and missed care is substantial it is unlikely that most care omissions are directly linked to staffing levels only” (Griffiths, et al. 2018). There is limited direct evidence of staffing levels on missed care indicating that more research needs to be done to adequately link the effect of staffing ratios and patient care. Another study assessed whether Massachusetts legislation for ICU nurse staffing was associated with better patient outcomes. The study concluded that patient outcomes did not improve with mandated patient-to-nurse ratios in Massachusetts ICUs. “In conclusion, Massachusetts General Law c. 111, § 231, which regulates the staffing assignments of nurses to patients in the ICU based upon patient acuity tools, failed to demonstrate improvements in patient mortality or complication rates among critically ill patients, potentially due to small effects on nurse staffing” (Law, Stevens, Hohmann, Walkey, 2018).
Many articles proposed that patient safety was not entirely dependent on staffing ratios but rather on the work environment and culture of the facility. “The environment in which care occurs also is an important predictor of patient outcomes…improvements, not only in staffing but also in the environment of care and support of higher learning for nurses, can have a tremendous positive impact on patient outcomes” (Fitzpatrick, Anen, Soto, 2013). In addition, authors reviewed an Illinois staffing mandate and examined the impact of committees designed to determine hospital staffing plans. The authors stated, “Documenting the influence of the Nursing Care Committees on patient outcomes is difficult at best…However, the observations and opinions of staff do provide an important insight into the relative effectiveness of this legislated model of nurse staffing” (Fitzpatrick, Anen, Soto, 2013). The authors concluded that while there is a positive impact of these nursing committees, research is ongoing to determine if they have actual influence on patient outcomes.
While there are reasonable arguments for and against mandated nursing staffing ratios, it is clear that more work needs to be done to understand the direct effects that nurse staffing levels have on patient outcomes. Jones, Bae, Murry and Hamilton state “Evidence of actual rather than presumed effects of nurse staffing regulations is needed to guide decision making for the diverse group of stakeholders with the common goal of improving patient care quality” (Jones, Bae, Murry and Hamilton, 2015)
There are also legal and ethical implications that are relevant to the argument of nurse staffing levels. If nurse staffing is inadequate and a patient experiences a preventable event, such as a fall or pressure ulcer, the facility and staff could be held accountable in a lawsuit. In a study examining the staffing standard in a large nursing home chain, authors state “This case study should be a cautionary tale that nursing home companies with understaffing are legally responsible for the negative effects on residents” (Harrington and Edelman, 2018). This is particularly true when management is aware of the effects of staffing levels on healthcare quality.
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In addition to legal implications of staffing ratios, nurses have a moral obligation to provide patients with optimal care. Nurses must follow a code of ethics outlining their professional obligations to patients. As Mensik and Nickitas state “The moral imperative to address nurse staffing goes beyond the financial viability of health care institutions and must include the safety issues patients face when their nurse cannot effectively manage the care related to his or her patient care assignments” (Mensik, Nickitas, 2015).
For bedside nurses working closely with patients, there are also implications on professional licensure. If a nurse is unable to complete his/her duties to ensure that the patient receives adequate care and a lawsuit ensues, the nurses license could be at risk. By inadvertently neglecting a patient due to patient overload, the case could be made that the nurse violating the state’s laws and regulations for the board of nursing. These are legal obligations that a nurse must abide to and if proven to be in violation, the nurse’s license could be at risk.
- Relevance to Healthcare Delivery
Because nurses are at the forefront in providing safe patient care, having adequate
staffing levels is important in the realm of healthcare delivery. In the previous study referenced above about heart failure readmission rates in MA, the authors noted that heart failure is the most common and most expensive condition among admissions to hospitals. By pointing out that this condition has such an impact on the healthcare system, it would be beneficial from a patient standpoint and even from a healthcare organizations’ perspective to improve nurse staffing levels.
Many studies propose that increased staffing levels would likely improve patient outcomes. “RN staffing is usually measured as the number of RNs given the number of patients, patient days, or hours of patient care. Nurse skill mix is the proportion of RNs to the total number of all nurses. Greater values of these measures are fairly consistently related to higher quality” (Unruh and Hoffler, 2016). Better nurse to patient staff ratios are generally associated with better patient care. “RN Staffing may be associated with lower gaps through an efficient use of resources that contributes to quality care” (Unruh and Hoffler, 2016). However, many arguments against mandated staffing ratios caution against the costs associated with increased staff and the impact on the institution’s ability to function within such a rigid budget. “Because nurse labor is a major driver of hospital costs, nurse staffing practices are particularly vulnerable to administrative scrutiny and often the target for lean management strategies” (Jones, Bae, Murry, Hamilton, 2015). I would argue that despite the initial costs of increased staffing levels, healthcare organizations would ultimately benefit from this investment. “Although a greater proportion of RNs may initially contribute to increasing operating costs in hospitals, cost savings and profitability in the long-run are achieved through improved productivity, such as reductions in adverse events (e.g. nosocomial infections), decreased length of stay and more efficient care processes” (Everhart, Neff, Al-Amin, Nogle, Weech-Maldonado, 2013).
- Theoretical Foundations
One conceptual framework that can be applied to the issue of nurse staffing and the
impact of mandated nurse-staff ratios is the General Systems Theory. The General Systems Theory was developed by Austrian biologist, Karl Ludwig von Bertalanffy to explain beyond the concept of a linear cause-and-effect. Anderson writes “von Bertalanffy described what has since become known as General Systems Theory, the concept that systems cannot be reduced to a serious of parts functioning in isolation, but that, in order to understand the whole, one must understand the interrelations between these parts” (Anderson, 2016). One of the principles of the general systems theory is “Exchange of information and matter (openness)” (Kearney-Nunnery, 2016, p.28). “Inputs come through the boundary from the environment, are transformed through system processes (throughputs), and are sent as outputs through the boundary back into the environment…an important component of this process is feedback from the environment” (Kearney-Nunnery, 2016, p.28). This statement highlights the importance of inclusivity when making staffing changes. Staffing levels are appropriately determined when there is adequate representation from key stakeholders. This includes hospital administrators, finance personnel, patient representatives, nurse administrators, and bedside nurses.
This theory brings a broader approach to healthcare management where we must consider all potential variables that impact patient safety. One of the variables that needs to be addressed is whether increased staffing could impact patient outcomes. Anderson writes “It is convenient to think about management as a linear process, each adverse event with an identifiable, antecedent cause. But how do we effect sustainable change based on this sort of simplistic view” (Anderson, 2016)? It is important to accept that delivering safe patient care is complex and requires a comprehensive evaluation of the many factors that affect patient outcomes.
Another applicable theory to issues related to nurse staffing is Imogene King’s Conceptual System. According to Kearney-Nunnery, this theory “focuses on the continuing ability of individuals to meet their basic needs so that they function in their socially defined roles” (Kearney-Nunnery, 2016, p. 36). In nursing, this theory could be simplified as a way for nurses to help their patients establish mutual goals to maintain their health to be able to function in their “roles” (Kearney-Nunnery, 2016, p. 36). These goals are established between the nurse and patient.
I would argue that the ability to determine safe staffing levels relies on establishing mutual goals between nurses and administrators. More specifically there needs to be an “agreement on means to achieve goals” (Kearney-Nunnery, 2016, p. 37). In other words, there should be an equal amount of input in deciding staffing levels. As Clancy states “If information flow is considered a network input, then tuning this variable to build consensus around specific issues will spontaneously create order within a complex system” (Clancy, 2004).
- Concluding Reflection
If mandate nurse-patient ratios passed in MA, I believe it would enable me to provide better care and feel confident that my patients are able to receive care to the best of my ability. Having better nurse-patient ratios would improve a nurse’s ability to provide better patient care, improving patient outcomes. It would be beneficial for hospitals to establish a work environment that supports nurses. In one study, Nantsupawat et al states “We found that a poor nurse work environment is the underlying factor of nurse attrition and turnover. We suggest that improving nurse work environment should be emphasized through policy to retain nurses in the workforce” (Nantsupawat, et al., 2016). In addition, adequate nurse staffing levels affect healthcare delivery. If patient safety and health outcomes can be directly associated with nurse staffing levels, then it would be appropriate for hospitals to advocate for better nurse-patient ratios. For example, one preventable factor related to patient safety is health care-associated infections. “Health care-associated infections (HAIs) are a serious patient safety issue that results in increased morbidity and mortality as well as excessive health resource utilization” (Mitchell, et al., 2018). The effects of HAIs on patient safety as well as the burden it places on healthcare resources, make it a priority issue for many hospitals. In this study the authors stated, “the findings suggest staffing to be associated with HAIs; increase levels of staffing seem to be connected to a decrease in the risk of acquiring HAIs” (Mitchell, et al., 2018). Given the tremendous burdens associated with HAIs, it would seem to be in hospitals’ interest to have uniform established staffing limits.
However, the challenge is determining what the ratio should be. “In principle, ratios represent a simple (some would argue over simplistic) approach to determining staffing levels. The main weaknesses of the use of nurse:patient ratios are their relative inflexibility and their potential inefficiency, if they are wrongly calibrated” (Buchan, 2005). There needs to be enough confidence from the nurses and administration to support a specific ratio. Without a mandate, it would depend on the facility. I believe some hospitals that are adequately staffed would not have any effect on their ability to provide safe patient care. For hospital nurses who feel they are unable to perform all their tasks because of time scarcity and understaffing, I believe they will continue to experience burnout and ultimately the patients would become more vulnerable to adverse events. Although coming to an agreement about what is considered a “Safe” nursing staffing level can be challenging, I believe the most effective way to alleviate the concerns of both nurses and administrators is to ensure that each individual or organization affected by this issue are able to participate effectively in the planning process.
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- Mensik, J., & Nickitas, D. M. (2015). Why Nurse Staffing Matters: A Moral Imperative. Nursing Economic$, 33(3), 186–187. Retrieved from http://ezproxy.snhu.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=26259345&site=eds-live&scope=site
- Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & Pogorzelska-Maziarz, M. (2018). Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature. The Joint Commission Journal on Quality and Patient Safety, 44(10), 613-622. doi:10.1016/j.jcjq.2018.02.002
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