A year-old man was admitted to the intensive care unit ICU with chronic obstructive pulmonary disease COPD exacerbation and atrial fibrillation with rapid ventricular response. He was markedly short of breath despite use of accessory muscles and was only able to speak in short sentences. He was alert and oriented but frail, and providers were concerned that he might tire and ultimately require mechanical ventilation. In the ICU that evening, two nurses scheduled to work had called in sick. There was only one patient care assistant scheduled on this weekend shift.
The Bureau of Nurse staffing ratio Statistics estimates that demand for registered nurses will increase 15 percent between andandnew nursing jobs will be Moms nude videos over this ten-year period. The California Department of Health Services had arrived at these ratios following a year of consultations with researchers from the University of California-Davis Medical Center, who based their recommendations on surveys they Nurse staffing ratio personally conducted of nurse directors throughout the state. September The main effective measure raito prevent injuries is to have an adequate amount of staff. In this area, best practices include the following: First, a centralized staffing office that assists the nurse leaders in adjusting the daily predicted budgeted staff vs. Related Resources.
My fist time with a teacher. Case Objectives
These standards can take various shapes, from the legislation in place in California since to proposals to require hospitals to establish nurse staffing committees that empower nurses to create facility-specific staffing policies, reviewing staffing levels for registered nurses, other professionals and support staff. Once the annual budget is approved, each nursing care unit develops monthly staffing and scheduling templates to ensure adequate Nugse staffing. High turnover rates and the overreliance on temporary nurse staffing increase the average cost per discharge cost of inpatient care, including administration and overall operating costs. His respiratory status also stabilized, and he Nurse staffing ratio the need for noninvasive ventilatory support and intubation and began to transition to intermittent, rather than continuous, nebulizer treatments. Beyond Nurse Blonde mom ass Ratios, Creating a New Reality Lisa Riggs, immediate past president of AACN, calls on all nursing and healthcare leaders to shift the conversation from nurse staffing being viewed as a hospital expense to an investment in patient safety. Specifically, these organizations feel that staffing patterns should not be mandated or standardized, but determined, created, and monitored i with input Gay boy teen video clips sperm direct care RNs and based on ii number of patients and acuity; iii number of admissions, Nirse, and transfers each shift; iv RN experience; v factors such as orientation Nurde unit, support staff, physical design of unit, vacancy, and turnover; and vi RN ratios benchmarked with specialty and hospital organizations. Target Audience. European Journal of Cardiovascular Nursing, 17 16— Safe Staffing Saves Lives. Download Nurse staffing ratio fact sheet as a PDF.
Nurse staffing legislation is being considered in at least 25 other states.
- We know that appropriate staffing ensures an effective match between the needs of the patient and family, and the knowledge, skills and abilities of the nurse.
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- A year-old man was admitted to the intensive care unit ICU with chronic obstructive pulmonary disease COPD exacerbation and atrial fibrillation with rapid ventricular response.
But just how many nurses should there be? Is there an ideal patient-nurse ratio? And should we require hospitals to strive for it? These are all points of ongoing debate. Hospitals across the country have growing caseloads of patients and limited numbers of nurses available to treat them—the consequence of 20 years of hospital downsizing due to state budget cuts and private mergers.
There are fewer nurses, all working longer hours and rushing through more patients during every shift, as a result. In , California began implementing a law requiring all of its hospitals to limit the numbers of patients that its nurses could treat at any given time. The limits would vary depending on the hospital setting. The California Department of Health Services had arrived at these ratios following a year of consultations with researchers from the University of California-Davis Medical Center, who based their recommendations on surveys they had personally conducted of nurse directors throughout the state.
To ask some nurses, the law was a godsend. Before it went into effect, some had as many as 10 or more patients to tend to at a time on every shift. They would wear themselves out trying to diagnose and treat each one. Every working shift was rushed and exhausting, and simple mistakes or missed cues became more common than they needed to be, inevitable side effects of nurses going on too much stress and too little sleep.
Citing surveys and nurse testimonials, the union attests that the no-longer-overworked nurses gained newfound time to give to each patient, and even time to give themselves occasional needed breaks. Procedural mistakes declined. And outcomes improved: Fewer patients got sick in the hospital, more recovered, and fewer had to return because of post-treatment complications.
But the change came at a price. Starting in , then-Gov. Arnold Schwarzenegger enacted a major boost in funding for nurse education programs. The investments worked, and within several years, the number of registered nurses in California grew by , Nearly a decade later, California is still the only state to have enacted a nurse-staff ratio law.
But nurse unions in other states are pressing their lawmakers to follow suit. They have several allies in the U. Congress, too. Barbara Boxer D-California introduced in April , would require hospitals to maintain minimum ratios of nurses to patients and would impose audits and fines on the hospitals whose ratios fall too low. There is fierce opposition, however, from the hospital executives.
Hospital associations protest that the laws would impose steep fiscal costs on them and would deprive hospital administrations of the right to make staffing decisions about their own wards. In some cases, the ratio laws might even leave some patients waiting longer to be treated, she added. The nurse might want to step away from those two and bring in another one or two patients from the waiting room.
The patients in the waiting room just have to go on waiting. She doubts that any state will be interested in taking up the challenge of nurse-staff ratio reforms, as well. There may be hope in education, however. McHugh supports that goal. Better-trained nurses will work better and achieve better patient outcomes even if they are challenged with large caseloads of patients, he explained.
Hospitals can give nurses more decision-making power and more workplace parity relative to the doctors. And this may translate to those nurses having higher morale and, by extension, putting in stronger job performance. McHugh noted that even the best-trained, most enthusiastic nurses will wear out if they are forced to tend to too many patients day after day.
But there is another ratio that causes McHugh even greater concern. If the United States wants more nurses, and ultimately a better nurse-to-patient ratio, then the first place to start would be upping the enrollment and training of student nurses.
That has a prerequisite, of course: more nurse faculty. McHugh also finds hope in the growing utilization of other health facilities besides hospitals. This is a great way to allocate health care more efficiently and thereby relieve some of the pressure on the hospitals, McHugh said. Other states have passed legislation relating to nurse-staff ratios, too, but not by prescribing set ratios like California has, he also noted.
For example, seven states—Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington—now require hospitals to have formal written policies on staffing and patient caseloads.
This can potentially avoid nurse overloading, since hospitals that plan ahead for busy days and staff absences will be less overwhelmed when the congestion happens.
This can reduce overcrowding by letting patients and nurses know which hospitals are the most crowded, the result of which will be some of the less-crowded hospitals getting more new patients and more nursing job applicants.
But he strongly supports the goal of maximizing the numbers of well-trained nurses relative to patients. Through a number of reforms, including not only laws but also new clinics, better workplace management, and expanded education, healthcare systems everywhere can achieve better results for both nurses and patients.
Toggle navigation. Photo: National Nurses United. Millicent Borland speaking at a strike over staffing levels. Photo credit: D. Map Click Here.
Rich has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. Appropriate nurse staffing helps achieve clinical and economic improvements in patient care, including improvements in patient and staff quality of life. Click HERE to learn more and register today! Your Stories. J Healthc Qual. But nurse unions in other states are pressing their lawmakers to follow suit.
Nurse staffing ratio. A Nurse Staffing Ratio Law
Since it was fully implemented in , research specific to California has shown measurably improved patient outcomes, in line with the broader academic consensus about the positive impact of lowering nurse workloads. The Bureau of Labor Statistics estimates that demand for registered nurses will increase 15 percent between and , and , new nursing jobs will be created over this ten-year period. This situation compromises care and contributes to the nursing shorting by creating an environment that drives nurses from the bedside.
Aside from the occupational hazards caused by understaffing and heavy workloads, numerous studies show a correlation between inadequate nurse staffing, poor nurse working conditions, and poor patient outcomes.
High patient-to-nurse ratios are associated with an increase in medical errors, as well as patient infections, bedsores, pneumonia, MRSA, cardiac arrest, and accidental death. The demands of the nursing profession are forcing many nurses to consider part-time nursing, or alternative careers. In a survey, close to 45 percent of the surveyed nurses said they planned to make career changes in the next one to three years, with over one-third of those surveyed considering careers outside of nursing.
In addition to enforcing mandatory overtime, employers often use supplemental nurses to temporarily fill gaps in nurse staffing. These temporary nurses are more likely to be concentrated in hospitals with poor staffing ratios and inadequate resources.
Temporary nurses make up between five and 15 percent of hospital nursing staffs in 55 percent of hospitals. Safe staffing may be an effective way to retain experienced nurses, lure those who left the field back, and attract students to the profession. The majority of available research shows that safe staffing practices are cost-effective for hospitals. High turnover rates and the overreliance on temporary nurse staffing increase the average cost per discharge cost of inpatient care, including administration and overall operating costs.
Safe staffing policies improve nurse performance and patient-mortality rates and reduce turnover rates, staffing costs, and liability.
The Role of Other Healthcare Professionals. While much of the debate and research surrounding the issue of hospital staffing focuses on registered nurses, many other types of professionals and support staff work in important and understaffed patient care roles as well. While nurse fatigue and the nursing shortage is lamented across the country, the push to boost hospital profit margins and reduce costs has left some nurses feeling left out of the conversation.
These standards can take various shapes, from the legislation in place in California since to proposals to require hospitals to establish nurse staffing committees that empower nurses to create facility-specific staffing policies, reviewing staffing levels for registered nurses, other professionals and support staff.
Nurses who are union members are also using their power at the bargaining table to push for improved staffing standards. Currently, 14 states have some type of law or regulation that addresses nurse staffing in hospitals. On the federal level, multiple attempts have been made to pass legislation in order to ensure safe staffing levels in every hospital, though none have been successful so far. Contact: Ethan Miller extension emiller dpeaflcio.
Implications of the California nurse staffing mandate for other states. Health services research, 45 4 , — The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis.
European Journal of Cardiovascular Nursing, 17 1 , 6— Kane, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical care, 49 12 , — Registered nurses. Occupational Outlook Handbook. Battling burnout in nursing.
Nursing Link. Journal of the American Medical Association. Chart Incidence rate and number of injuries and illnesses for selected occupations with 20, cases or more, all ownerships, Overtime work and incident coronary heart disease: the Whitehall II prospective cohort study. European heart journal, 31 14 , — Laschinger, et al. Medical care, 54 1 , 74— A cohort study. Annals of intensive care, 7 1 , The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.
Health affairs Project Hope , 31 11 , — Nurse staffing, burnout, and health care-associated infection. American journal of infection control, 40 6 , — We need more nurses. The nurse then hurriedly returned to the bedside of the acutely ill patient with the pulmonary embolism. Approximately 5 minutes later, the patient care assistant arrived at the COPD patient's bathroom and found him slumped on the floor, unresponsive and cyanotic with his oxygen detached from his face.
A code blue was called but, despite extensive resuscitation attempts, the previously "stable" ICU patient was pronounced dead. While we are not provided with details regarding the physiologic causes of this tragic outcome—it is possible that it was unrelated to the staffing—the case highlights the tensions involved in determining appropriate nurse staffing ratios and policies that exist or need to exist to ensure patient safety.
The solutions are multifaceted, and all solutions begin with the nursing culture of the organization and the unit. Commonly Used but Inadequate Options. The previous discussion focused on policies at the hospital level to ensure adequate staffing on each unit. But even in hospitals with such staffing policies, situations will arise in which nurses find themselves being stretched to the limits. How should nurses and the systems in which they operate respond? The first option for this staff nurse was to discuss with the nurse manager or charge nurse his or her specific concerns about caring for three ICU patients and collaboratively establish a new plan of care for all patients during that shift.
An appropriate leadership intervention would have been to validate the staff nurse's concerns and develop a solution. Solutions that are commonly used include: i reassigning a nurse from another comparable unit where acuity is lower, ii reprioritizing and readjusting the workload of all nurses on the shift, and iii having nursing management personnel extend their hours of work into the shift or come in early to help.
In my view, while these actions appear to solve the problem at hand, these "fix-the-bridge-as-you-walk-on-it" solutions are not sustainable. When invoked routinely, they cause increased stress, emotional and physical fatigue, and compromised patient safety. Staff nurses who endure such shortages shift after shift do feel that care is unsafe.
Again, while this ameliorates the situation in the ICU, it often exacerbates staffing problems in the emergency department. Over time, if overcrowding in any venue of care persists, all care providers become overtaxed and anxious.
Disrespect for one another begins to flourish, and patient care can become secondary to unit and caregiver needs. Other inadequate options are i mandatory or voluntary overtime and ii returning to work on an on-call basis but still working the next day. This translates to working hours at one time.
Robust research has demonstrated that these strategies are associated with poorer patient outcomes. Best Practice Options. The best approach to unplanned staffing deficits is to proactively define the action steps to take prior to the crisis. This action plan is defined by the approach articulated in Part 1.
Nurse unit leaders must anticipate changing staffing needs and assess at least hours prior to the next shift if staffing ratios and patient needs can be met. If unpredictable events occur, staff nurses must feel empowered to voice concerns and collaborate with nurse leaders, shift coordinators, and physicians to make decisions that protect patients first.
This commentary has expressed both proactive and just-in-time approaches to making patients safe. The budgeted staffing ratios must be planned with staff nurse input and support, and their decision making must be respected. Danger points for shortages of staff are weekend shifts and times of high emergency department census. Nursing leadership must proactively design incentives for nurses to work on weekends and plan for adjusting staffing levels when volume increases before the problem actually occurs.
Chief Nursing Officers CNOs must constantly balance the financial management of nurse staffing against the needs of patients. As budgets tighten, it is vital that nurse leaders maintain RN ratios when census is high and decrease RN staffing when census is low.
The flexibility of a resource pool and keen daily budget management enable the CNO and other nurse leaders to follow budgeted staffing plans and instill trust and confidence in the staff nurses that patient care ratios will be protected. When RN ratios are adhered to, patients receive safe, quality care and nurses are recruited and retained. It is not rocket science. Best practices in dealing with nurse staffing ratios include:. Faculty Disclosure: Dr.
Rich has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity.
In addition, her commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices. Giovanetti P. Staffing Methods — Implications for Quality. In: Measuring the Quality of Care. Edinburgh, NY: Churchill Livingstone; ISBN: Nursing resource management: analyzing the relationship between costs and quality in staffing decisions. Health Care Manage Rev. Nurse staffing and patient outcomes.
Nurs Res. Nurse experience and education: effect on quality of care. J Nurs Adm. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. In: Hughes RG, ed. Institute of Medicine. Safe Staffing Saves Lives. Nationwide State Legislative Agenda, Reports.
Perspectives on Staffing and Scheduling. The National Database. Published July Spotlight Case. Approach to Improving Safety. Failure Mode Effects Analysis. Nurse Staffing Ratios. Setting of Care. Intensive Care Units. Clinical Area. Critical Care. Critical Care Nursing. Target Audience. Nurse Managers. Quality and Safety Professionals. Facebook Twitter Linkedin Email.
Update on Nursing Staff Ratios
Nurse staffing legislation is being considered in at least 25 other states. Nurse staffing ratios were relatively unchanged from to and then increased significantly from to , with the largest increase in , the year the nurse staffing ratio was implemented. Nurse staffing legislation may increase nurse staffing. Journal of Hospital Medicine ;— These studies coupled with increasing concern about patient safety, nursing shortages, and nurse burnout have spurred many state legislatures to discuss mandating minimum nurse staffing ratios.
The original implementation date, January 1, , was delayed to allow the California Department of Health Services more time to develop minimum nurse ratios for each unit type. This was subsequently increased, on January 1, , to at least 1 licensed nurse for every 5 patients, a ratio that was upheld by the California Supreme Court on March 14, Additional laws regarding nurse staffing are being considered in at least 25 states.
However, little is known about trends in nurse staffing, how staffing levels vary among hospitals overall, in different markets, and by ownership type and location, and consequently how implementing nurse staffing ratios will affect different types of hospitals, including those that make up the safety net.
California nurse staffing data are better than many other sources because the state provides nurse staffing hours by unit types in hospitals as opposed to aggregate numbers of nurse hours across an entire hospital or medical center. Examining nurse staffing trends and hospital types currently under mandated or proposed nurse staffing ratios is integral to informing the debate on nurse staffing legislation and its effect on hospitalists.
We calculated the number of patients per one nurse by dividing 24 by the nurse hours per patient day eg, 4. We did not adjust staffing ratios by the hospital case mix or other factors because the ratio legislation did not take these factors into account. Hospital ownership was designated as for profit, nonprofit, or government owned. Market boundaries were defined as those zip codes from which each hospital draws most of its patients.
Location was defined by county location as either urban or nonurban medical service area. The nurse staffing ratios were essentially flat from to without any significant trend. From to , the median hospital staffing ratio increased from fewer than 1 nurse per 4 patients to a ratio of more than 1 nurse per 4 patients. Hospital nurse staffing ratio trends — The legislation in California and the proposed legislation in some other states allow hospitals to meet mandated ratios with both RNs and LVNs or LPNs, that is, with licensed nursing staff.
Therefore, we analyzed the overall trend in percentage of nurse staffing hours attributable to LVNs. The next column represents the hospitals below the ratio of at least 1 licensed nurse per 5 patients, which was implemented in The final 2 columns represent ratios that have been considered in other states of at least 1 RN per 5 patients and at least 1 licensed nurse per 4 patients. This demonstrates the substantial increase in the proportion of hospitals that are below minimum ratios as the number of nurses or required training level of nurses is increased.
From to , there was a decrease in the percentage of hospitals below all the ratios. The absolute decrease was least in the actual mandated ratio in of at least 1 nurse per 6 patients 5.
Although there was a decrease in the percentage of hospitals of all types below the minimum ratios from to , some hospital types had larger reductions in hospitals below ratios than others.
These safety net hospitals also failed to achieve the significant decrease in percentage of hospitals below minimum ratios from to that hospitals with a low Medicaid population achieved. There were a total of 38 of hospitals These data demonstrate that nurse staffing ratios in California were relatively stable from to In , law AB with its focus on nurse staffing levels passed, and subsequently, from to , nurse staffing levels increased significantly, with the largest increase in , the year of implementation.
Although multiple factors could account for this trend, a likely cause for the statewide increase in nurse staffing was the anticipation and then implementation of legislation to achieve minimum ratios. This study had several limitations. These data may overreport nurse staffing hours if they include hours not spent in direct patient care, or they could misrepresent nurse staffing ratios because of poor reporting. Certain hospitals are more likely to be below mandated ratios.
Hospitals with these characteristics are typically considered part of the safety net. These are the hospitals that serve our nation's most vulnerable populations and are likely to struggle disproportionately to meet minimum mandated ratios. These potential tradeoffs will directly affect hospitalists, nurses, and other health care personnel working in hospitals.
Because legislation generally does not provide funds or mechanisms to help hospitals meet proposed staffing ratios and there is a national nursing shortage, hospitals may struggle to meet minimum ratios.
The potential for unintended but serious negative consequences exists if hospitals in the safety net are mandated to meet minimum nurse staffing ratios without adequate resources. At all types of hospitals, hospitalists are increasingly becoming responsible for quality improvement programs and outcomes measurement. However, the outcomes of these programs may be strongly influenced by nurse staffing. Therefore, hospitals and their hospitalists must take into account the effect that inadequate nurse staffing could have on their patient outcomes while balancing the investment in nurse staffing with other quality improvement investments.
An interaction between nurse staffing level and hospitalist staffing may exist, but we are unaware of any published studies investigating this interaction. The nurse burnout documented to be associated with inadequate nurse staffing certainly could affect hospitalists if it increases nurse turnover or inhibits effective communication.
Finally, these data highlight the need for policymakers and hospital administrators to consider whether the aim is to establish a minimal floor or an optimal ratio. In addition, some states such as Massachusetts have considered a minimum ratio of Only a few studies have estimated the cost effectiveness of staffing changes. Rothberg et al. The effect on patient outcomes when hospitals move from to or nurse staffing levels needs to be determined in a longitudinal study.
Thus, legislators and hospitals have little to guide them in establishing optimal nurse staffing ratios, and consideration of specific mandated minimum ratios would benefit greatly from comparative information on the cost and quality tradeoffs.
Hospitals, policy makers, health care providers, and researchers are struggling to improve the health care delivered in our hospitals; fortunately, there has been an increased focus on the importance of nurses who deliver medical care on the front lines and are responsible for many aspects of quality. Mandating minimum nurse staffing ratios may seem like an easy fix of the problem; however, we must consider how these ratios can be met, the potential difficulty for hospitals to meet these ratios in the fraying safety net 20 , and possible unintended negative consequences.
Without a mechanism for hospitals to meet ratios, simply mandating a minimum ratio will not necessarily improve care. Hospitalists should be leaders in better understanding the effects of nurse staffing on patient outcomes and quality initiatives in hospitals.
Skip to main content. Original Research. Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net. By: Patrick H. RESULTS: Nurse staffing ratios were relatively unchanged from to and then increased significantly from to , with the largest increase in , the year the nurse staffing ratio was implemented. Figure 1 Hospital nurse staffing ratio trends — Current Issue. Menu Close.