Nurse to Patient Ratios:

The Journey to Improving Patient Outcomes & Increasing Nursing Job Satisfaction

Jasmin Smith, RN

College of Central Florida

February 10, 2016

             Providing patient centered care should be the ultimate goal of the Registered Nurse, however; this goal is becoming almost unattainable as RN’s battle the effects of mismatched nurse to patient ratios. Recently HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems, scores have been implemented to evaluate how hospitals and their staff are meeting nationwide goals in implementing successful patient outcomes, i.e lower nosocomial infections, patient satisfaction, and lower failure to rescue rates; but consequently, the reviewers do not seem to take to heart that outcomes can be influenced by many situations in the hospital setting, including nurse to patient ratios. Currently there is no clear-cut definition when it comes to breaking down the true meaning of “nurse-to-patient” ratios due to fact that this interpretation is up to the discretion of the nurses’ employer, although it is often discerned as the nurse’s number of patients assigned in a given shift. As we delve into the topic of nurse to patient ratios affecting patient’s outcomes, nurse satisfaction levels and the costs involved in this endeavor, we must remain unbiased in our approach, as there are both motivators and setbacks associated with implementing regulations.

       One of the major issues associated with high patient to nurse ratios is nurse burnout and failure to rescue. As more and more tasks become expected of the RN it is hard for nurses to truly carry out patient centered care, and a more task-oriented approach is adopted. A study conducted by the Institute of Medicine in 2010, as cited in Hinno, Partanen & Vehviläinen-Julkunen, (2011), discovered that there is sufficient evidence to prove that a nurses’ day is primarily consumed by tasks such as documentation, medication administration, and coordination of care. This research study even provided findings showing “ less than one-fifth of nursing practice time is spent on direct patient care activities, such as performing procedures and care at the bedside and just seven percent [of nurses’ time] is used on patient assessment and monitoring vital signs” (p. 1585). By becoming task focused, nurses can compromise patient care by treating patients as assignments, not people, and forget to implement holistic measures thus decreasing patient satisfaction.

               On a personal level, nurses may start to question their career choice, or fear for their license when the patient load becomes too heavy, or the acuity of the patients unsafe for a single nurse to handle efficiently. Many hospital units function in numerical increasing districts, i.e. nurse A is responsible for rooms 115-120, a method that can backfire and leave nurses feeling overwhelmed, and decrease morale, if proper attention to patient acuity is not addressed by the charge nurse making the district assignments. When chronological districts are used a nurse may walk into a district with three patients needing blood transfusions during the shift, while the other patients may have dressing changes and sugar issues that also require close monitoring. While the initial thought process in implementing chronological districts is of the assigned nurse being in close proximity to their assignments, realistically the nurse can only be in one place at a time. Such heavy assignments can correlate with failure to rescue due to fatigue and miscalculated prioritization due to multiple high acuity needs. Also, some hospitals cluster higher acuity patients closer to the nurse’s station, in order to provide a quicker response when crises arise. This clustering of higher acuity patients can leave the nurse feeling overwhelmed, dissatisfied, and questioning biases with repeated higher acuity assignments. As Thomasos, Brathwaite, Cohn, Nerey, Lindgren, & Williams, (2015) points out, when assignments are being made “the amount, complexity, and time needed for nursing tasks required by each patient must be considered. The patient’s disabilities and cognitive state are threats to his or her safety, and relate to the degree of vigilance needed” (p. 40). A solution to acuity clustering, is not implementing chronological assignments, but rather acuity considered assignments, meaning the assignments can be scattered around the unit. Although this may take some extra time, and nurses may not be in favor of their assignments being spread out, it takes into consideration balancing out the acuity load and allows the nurse time to gain professional composure when exiting one patient’s room, and the ability to focus one’s thoughts on the next patient’s needs. Although this is one solution to battling high acuity assignments the ultimate need is lower patient to nurse districts. Serratt’s (2013) review of the mandated minimal ratios (MMRs) enacted by California in 1999, reported that an increase in nurse staffing levels not only improved working conditions but also decreased nurse turnover rates in the state. After reviewing numerous studies conducted in various clinical settings Hinno et al., (2011), concluded that there is sufficient evidence showing “ a higher proportion of RN’s is associated with shorter hospital stays and lower failure-to-rescue rates” (p. 1585).

   Currently in the U.S., nursing regulations are made on a state-to-state basis. Each state has incorporated legislative approaches that address nurse staffing concerns, as pointed out by Munier & Porter (2014).   The main avenue used to regulate nurse staffing is through incorporating hospital nurse staffing committees, better known as HNSC’s. In 2013 the U.S. House of Representatives enacted the Registered Nurse Safe Staffing Act, encouraging that such committees be composed of at least 55% bedside nurses, with the remaining percentage being composed of nurse managers and “other hospital personnel” (Munier et al., 2014). The thought process behind this is that if bedside nurses make up the majority of the HNSCs that hospital specific staffing levels can be implemented based upon the needs seen by the RN’s and not the government. Currently, per Munier’s (2014) report, the ANA, American Nursing Association, is supportive of the HNSC approach, as opposed to MMR’s in incorporating lower patient to nurse ratios, but there are still mixed feelings about the issue.

     Despite nurse-to-patient ratios being recognized as an area needing reform in the healthcare setting, so far only one state in the U.S, California, has implemented state mandated ratios. Part of this stall is contributed by the controversy surrounding the topic. When new bills are presented they are met with concerns that if MMRs are mandated, they will be implemented as a “generic” intervention, which cannot possibly address individual hospital needs. In 2003 the American Organization of Nurse Executives, as cited by Munier et al., (2014), claimed “because staffing is a complex issue composed of multiple variables, mandated staffing ratios, which imply a ‘one size fits all approach, cannot guarantee that the healthcare environment is safe or that the quality level will be sufficient to prevent adverse patient outcomes” (p. 598). Sadly this is a misconception because California’s MMR’s are not cut and dry but rather there are 17 different MMRs based upon staffing needs perceived in specific hospital units.

     Many hospitals are switching to a “for profit” foundation. This change creates yet another barrier for implementing lower patient to nurse ratios as a higher nurse to patient ratio is viewed as a unnecessary expense; or that the measures needed to recruit more RNs, i.e. bonuses, hiring traveling nurses, or offering more competitive wages, not to mention the training costs associated with new hires, are not considered cost effective. However, a recent study conducted by the Journal of Advanced Nursing ( JAN) found that overall when patient to nurse ratios were reduced there was an average of $400 savings per hospitalized patient when non-overtime RNs were used (Twigg, Geelhoed, Bremner, & Duffield, 2013). A contributor to this study named Rothberg estimated that when patient-to-nurse ratios are decreased from approximately 1:8 to 1:4, patient mortality level and costs are directly influenced. He projected that such a reduction would reduce “patient mortality and costs to $136,000 per life saved” (as cited by Twigg et al., 2013, p. 2255). This cost compares positively to other therapy interventions such as thrombolytic administration or routine cervical cancer screenings which report costs of $180,000- $432,000 per life saved (Twigg et al., 2013).

       Another variable that current nurses have no control over is the nation also faces another setback when tackling nurse to patient ratios: nursing shortages. A report compiled by the American Association of Colleges of Nursing (AACN), based upon statistics retrieved from the Bureau of Labor’s 2013 report, predicts that the nursing profession will grow by 19% by 2022, and that the total number of job openings for nurses due to growth and replacements will be approximately 1.05 million (as cited by AACN, 2013). However, the economy is in dire times and the job security nursing offers has prompted many in America to go back to school to pursue this career.

     Although many view California’s “success” with implementing MMRs not substantial evidence to move forward in implementing similar statutes in other states, the American Journal of Nursing, (AJN), in an article by Laura Wallis, cites that “numerous studies support the claim that California’s law has led to more hiring, increased job satisfaction, less burnout, and better retention of nursing staff- and it was a factor in resolving the nursing shortage in the state” (Wallis, 2013, p. 21). Despite these feelings many still question if a correlation between lower patient to nurse ratios indeed result in better patient outcomes. In the same article, Linda Aiken PhD, RN, FAAN voices her support in California’s approach and as proof that it was effective compared it to two other states’ that do not implement MMR’s, Pennsylvania and New Jersey, and their reported patient outcomes regarding deaths associated with surgical complications (Wallis, 2013). As cited from Aiken’s findings they estimated “that there would have been 13.9% fewer surgical deaths in New Jersey, and 10.6 % fewer surgical deaths in Pennsylvania, if the hospitals had staffing ratios equivalent to those in California” (Wallis, 2013, p. 21).

     After reviewing all these articles I believe that there is sufficient evidence to support that when lower patient to nurse ratios are incorporated in the healthcare setting, the result is an improvement in patient outcomes, and nursing satisfaction. There is a decrease in failure to rescue, an increase in nurse retention rates, and despite popular belief a decrease in hospital associated costs. Still the battle goes on, and as this topic is heavily debated in the nursing world the current solution is for nurses to voice their opinions and to advocate for both patients’ and nurses wellbeing. Whether HNSC’s or MMR’s are implemented in one’s healthcare setting, it is up to the nurse to proactively voice their concerns and break down the barriers hindering lower patient–to-nurse laws from being passed. Hopefully, the world will soon recognize that the benefits to lower patient to nurse ratios, surpass any controversy associated with the topic.

References:

American Association of Colleges of Nursing. (2013). Nursing shortage. Retrieved from

               http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage

Hinno, S., Partanen, P., & Vehviläinen-Julkunen, K. (2011). Nursing activities, nurse

           staffing and adverse patient outcomes as perceived by hospital nurses. Journal of

           Clinical Nursing, 21(11-12), 1584-1593. doi:10.1111/j.1365-2702.2011.03956.x

Munier, T., & Porter, S. (2014). The struggle for safe staffing levels in the USA: A

             political economy of evidence-based practice. Journal of Research in Nursing,    

             19(7-8), 592-603. doi:10.1177/1744987114557108

Serratt, T. (2013) California’s nurse-to-patient ratios, Part 1: 8 years later, what do we

             know about nurse-level outcome?. Journal of Nursing Administration, 43(9),

             475-480. doi:10.1097/NNA.0b013e3182a23d6f

Thomasos, E., Brathwaite, E.E., Cohn,T., Nerey, J., Lindgren, C.L., & Williams, S.

             (2015). Clinical partners’ perceptions of patient assignments according to acuity.  

             MEDSURG Nursing, 24(1), 39-45.

Twigg, D. E., Geelhoed, E. A., Bremner, A. P., & M. Duffield, C. (2013). The economic

             benefits of increased levels of nursing care in the hospital setting. Journal of

             Advanced Nursing, 69(10), 2253-2261. doi:10.1111/jan.12109

Wallis, L. (2013). Nurse–patient staffing ratios. AJN, American Journal of Nursing,

             113(8), 21. doi:10.1097/01.naj.0000432956.03387.bd