Minimum Nurse to Patient Ratios in
Hospitals

Goran Yaksic

HAP 465

George Mason University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction

In the United States today, according to
the Kaiser Family Foundation, there are approximately 4 million professionally
active nurses (Total Number of, 2017). On the other hand, there are about 320
million people in the United States. Many times, as a result, there are minimum
nurse to patient ratios in hospitals. Furthermore, due to the rigorous nature of a nurses’ job, including their hectic
schedule, it may be challenging at times to provide the most optimal care to
everyone. However, quality of care is a key component in all healthcare
institutions; therefore, providing desired health outcomes that are consistent
with one’s professional knowledge should be a top priority. Both State and
Federal governments should work together to mandate a higher nurse-to-patient
ratio in hospitals to reduce complications that result from nurses working
longer shifts, and at the same time, increase patient satisfaction.  The minimum nurse to patient ratios in hospitals
is a critical compliance component; nurses should be mandated by both state and
federal government to assure quality of care.

Background

Nurses
are usually highly qualified professionals that provide and coordinate patient
care, educate patients and the public about various health conditions, and
provide advice and emotional support to patients and their family members
(Bureau of Labor). Important qualities that a nurse usually possesses are
critical thinking skills, communication skills, compassion, detail oriented,
emotional stability, organizational skills, and physical stamina. Registered
nurses must assess changes in the health status of patients, such as
determining when to take corrective action and when to make referrals (Bureau
of Labor). They must also be able to communicate effectively with patients in
order to fully understand their concerns and assess their health conditions as
a result. Nurses also need to have the ability to clearly explain instructions,
such as how to take medication. They must know how to work in teams with other
health professionals and be able to relay the patients’ needs. Finally,
registered nurses should be caring and empathetic when looking after patients
(Bureau of Labor).

For decades, nurse shortages have
served as major obstacles to the introduction and sustainability of nursing
innovation. Currently, nurse shortages are the longest they have been since 1998.
Furthermore, they have been offered as a justification for why improved nurse
staffing in hospitals should not be mandated and why policy requirements for
nurse staffing in nursing homes should remain low. This shortage of nurses was
advanced by stakeholders in opposition to California’s mandated minimum nurse
staffing ratio legislation that was subsequently passed and later upheld by the
California courts (Aiken, 2008). However, several studies have shown a direct
correlation between investments in nursing and better patient outcomes. Additionally,
at least one study has empirically shown that the odds of hospitals’ achieving
quality targets that would trigger payment premiums under pay for performance
are increased as registered nurse hours per patient day increase (Aiken, 2008).

In 1984, hospital
nurse vacancy rates were at an all-time low of less than 4%. As a result, some
hospitals eliminated positions and/or required nurses to reduce their paid
hours. However, just two years later, nurse vacancy rates in hospitals had more
than doubled and hospitals nationwide were reporting a serious shortage of
nurses. When the shortage began, graduations from nursing schools were at a
historic high: almost 85,000 a year. Furthermore, inpatient hospital days also
fell by 51 million annually between 1981 and 1987 as a result of incentives from
the hospital prospective payment system (PPS) for shorter hospital stays. This
scenario, of large numbers of new RN graduates and huge reductions in inpatient
days, was surprisingly consistent with nurse surplus rather than shortage, however
hospitals nationwide were soon reporting high RN vacancy rates again.

Nursing is generally considered a
“cost” rather than revenue in a hospital context, which makes nursing a
constant target for cost reductions. Because institutions are not directly
compensated for providing nursing care, unlike physician services, there is
little motivation to provide an adequate amount of nursing to meet patients’
varying needs. The legacy of PPS with its incentives to reduce hospital length
of stay (LOS) ever further has been very detrimental for nurses as more complex
care is compacted into fewer days. The highest rates of burnout are generally
found among nurses in countries with shorter LOS. Among Western countries,
burnout is highest in the United States where LOS is shortest. Research
suggests that high nurse burnout is a contributing factor to expensive nurse
turnover, is associated with patient dissatisfaction, and is a threat to
patient safety.

Several strategies for determining
nursing cost offsets has been pursued by Aiken and associates to evaluate the
relative impact of different types of investments in RNs. Aside from staffing and
work environment, they have also looked at education. In a study conducted in 2003
on the joint effects of nurse staffing and education on mortality, the lowest
mortality was found in hospitals where nurses on average cared for 4 patients
each and 60% had a bachelor’s degree. On the other hand, the highest mortality
was found in hospitals where nurses cared for an average of 8 patients each but
only 20% had bachelor degrees. Finally, the mortality is the same in hospitals
where nurses care for an average of 8 patients each but at least 60% have a bachelor’s
degree and hospitals where nurses care for 4 patients each but only 20% or less
have a bachelor’s degree. It is presumed that management decisions can impact
the proportion of nurses in a hospital with baccalaureate education through
selective recruitment, retention, and support for existing staff to obtain higher
education.

Care in an
environment where the overall educational levels of nurses is higher may afford
certain patients that would normally require more staff where the nurse
workforce is less educated. These findings raise the potential that a smaller
RN workforce might be possible in the future if the overall educational levels
were higher. Currently however, only 43% of staff nurses have bachelor’s
degrees, which means there are not enough nurses for all hospitals to have at
least 60% with a minimum of a bachelor’s education. More than 60% of new nurses
now graduate from associate degree programs and relatively small proportions
appear to be going on to obtain their bachelor of science in nursing degrees.

            According to the bureau of labor statistics in 2016, the
median annual wage for registered nurses was $68,450. The lowest 10 percent
earned less than $47,120, and the highest 10 percent earned more than $102,990.
The top workplace for industries in descending order were as follows:
Government, Hospitals, ambulatory health services, nursing and residential care
facilities, and educational services. Nurses who worked in the second highest
paying industry, hospitals, earned a median of $70,590 (Bureau of Labor).
Nurses for the most part however, don’t make much money considering how much
work they have to do. Their long and demanding schedules leads to increased
fatigue, more burnout, more on-the-job injuries, and have an impact on their
overall health (Ericksen, 2016).

The
majority of registered nurses work either eight or 12-hour shifts. Nurses who
work eight-hour shifts tend to work around 40 hours per week, and nurses who
work 12-hour shifts tend to work about 36 hours per week. For example, a
typical day in the life of a nurse working a 12-hour shift consists of waking
up around five in the morning, relieving the nurse that had worked the night
shift around seven, begin performing the traditional morning rounds an hour
later at eight, lunch at noon, a continuation of rounds at one, and begin
preparing everything for the night shift around six (A Day in the, 2017). Despite
regulations on shift length and cumulative working hours for resident
physicians and workers in other industries, there are no national work-hour
policies for registered nurses (Ericksen, 2016).

             

Supporting Argument

A
nurse may sign up for a 12-hour shift, however many 12-hour shifts may result
in overtime and thus lead to increased fatigue. Studies show that nurses who
work longer hours exhibit higher instances of burnout. Nurses who worked shifts
10 hours or longer were two and a half times more likely to experience burnout
and job dissatisfaction (Ericksen, 2016). Furthermore, burnout can cause
employers to lose valued employees. According to a study conducted by the
National Institute of Nursing Research, patients were less satisfied with nurses
who worked 13 or more hours, and more satisfied with nurses who worked 11 hours
or less (Ericksen, 2016). Another study conducted by the Agency for Healthcare
Research and Quality linked shorter shifts with fewer errors; strains of long
shifts can manifest in mistakes, mistakes with severe consequences. Longer
shifts also result in nurses being more susceptible to injuries, such as
strains and needle sticks. Finally, nurses who regularly work long hours may
see a negative impact on their health. Several studies have found an increased
risk for a multitude of health issues, including musculoskeletal disorders,
gastrointestinal problems, gastric ulcers, obesity, diabetes mellitus,
metabolic syndrome, cardiovascular disease and cancer (Ericksen, 2016).

Nurses
have an integral role in the health care system. State-mandated safe-staffing
ratios are necessary to ensure the safety of patients and nurses. Adequate
nurse staffing is key to patient care and nurse retention, while inadequate
staffing endangers patients and drives nurses from their profession. Staffing
problems will only intensify as baby boomers age and the demand for health care
services grows, thus making staffing ratios a pressing concern (Safe-Staffing
Ratios, 2016). Additionally, every patient that is added to a hospital nurse’s
workload is associated with a seven percent increase in hospital mortality.
According to the American Nurses Association (ANA), Massive reductions in
nursing budgets, combined with the challenges presented by a growing nursing
shortage have resulted in fewer nurses working longer hours and caring for
sicker patients. This particular situation compromises care and contributes to
the nursing shortage by creating an environment that drives nurses away from
bedside patients (Safe-Staffing Ratios, 2016).

 In 2004, California became the first state to
implement minimum nurse-to-patient staffing ratios, designed to improve patient
care and nurse retention (). As of January 1, 2008, the ratio law completed its
“phase-in period” and has now been updated, by the California
Department of Health Services (DHS), with new mandated minimum numerical ratios
for three units. Step Down has been reduced from 1:4 to 1:3, telemetry from 1:5
to 1:4 and other specialty care units, such as cancer care, from 1:5 to 1:4 (Arevalo).
Furthermore, Pediatrics had a ratio of 1:4, Emergency room a ratio of 1:4, and
Medical/Surgical 1:5. These three units are the most crucial to assuring
quality of care, and therefore, need the most change. Pediatrics should
increase their ratio to at least 1:2, not only to remove stress from nurses,
but to also allow them to deliver the highest quality of care possible.
According to the CDC, the emergency room receives about 141 million people per
year of which 40 million are injury-related, 1.8 million go to the Intensive
Care Unit, and only 32 percent are seen in less than 15 minutes (Emergency
Department Visits, 2017). These numbers should indicate how important it is to
increase the minimum nurse-to-patient ratios in the emergency room. The 1:4
ratio as of now, should be increased to at least 1:2 to allow for faster
admission times and higher quality of care delivered to patients. As for the
1:5 ratio for Medical/Surgery, this ratio should be increased as well. Not only
would a 1:3 ratio be better for patients, nurses, and doctors, but it would
also provide good reputation for the hospital itself. States should therefore
mandate hospitals to increase nurse-to-patient ratios so that nurses may have
less stress, and as a result, deliver higher quality care to patients.  

Opposing Argument

Working
longer shifts however, also has its perks. Longer shifts promise less patient
turnover, provide better work-life balance, require less commuting, offer
greater flexibility, are easier to schedule, and improve morale (Ericksen,
2016). The most prominent benefit of longer shifts is the decrease in handoffs.
Instead of three or more nurses attending to a patient in the span of one day,
only two will be needed with 12-hour shifts. Less handoffs between nurses mean
less reports and less chances for miscommunication and possible error
(Ericksen, 2016). Nurses who work 12-hour shifts also generally have four-day
weekends. Not only does this mean more flexibility and time to spend with
family, but it also implies less commuting which can save money and protect the
environment at the same time. Finally, 12-hour shifts, improve absenteeism
amongst nurses, boost morale, and increase retention (Ericksen, 2016).

Truth
be told, there is no typical day for a nurse. Every single shift has the
potential to be exhilarating, exhausting, and energizing, or all of the above.
On any given day, nurses can see people at their weakest and most vulnerable,
or at their strongest and fully determined (A Day in the, 2017). They are also
frequently witnesses of the results of both career-ending and/or life-ending
injuries and illnesses. Therefore, it’s almost impossible to portray a typical
day for a nurse, given how different their workplaces can be, and how duties
may vary from shift-to-shift depending on which patients he/she needs to see.

Increasing
nurse-to-patient ratios may also pose to be a problem, particularly for
management. From a managerial standpoint, longer shifts are much easier to
schedule; equivalent to one less shift to schedule every day. Also, assigning
more nurses to a particular unit may also be an issue. Additionally, from a
hospital’s perspective, hiring more nurses would mean a much larger investment
of money. This is considering that on average, registered nurses make $68,450
annually; they could also be making more depending on their level of education
and experience.

Conclusion

Regardless
of working shorter or longer shifts, quality of care
is one of the most important aspects of healthcare. Providing the desired
health outcomes that are consistent with one’s professional knowledge should be
a top priority. However, based on a compelling amount of evidence, there is an
indication that increasing the minimum nurse-to-patient ratios in States could
prove to be beneficial for both nurses and patients alike. Nurses should be
allowed to continue choosing what shifts they want to work, however they should
perhaps be incentivized by both federal and state government to take shorter
shifts based on the research that has been conducted. The burnout
scores for bedside nurses in U.S. hospitals are among the highest recorded in
research about human services workers. Despite the shortage, nurses spend
considerable time on tasks that do not require their special knowledge and
expertise, while needed nursing care is left undone (). Aside from the
occupational hazards caused by understaffing, numerous studies show a
correlation between inadequate nurse staffing and poor patient outcomes. High
nurse-to-patient ratios are associated with an increase in medical errors, as
well as patient infections, bedsores, pneumonia, MRSA, cardiac arrest, and
accidental death (Safe-Staffing Ratios, 2016). Although a nurse’s
salary, stress, and extra work all play a major role in how he/she acts at
work, delivering quality care to patients should still be a top priority.
Therefore, minimum nurse to patient ratios should be addressed by both federal
and state governments in hospitals. Increasing this number in the most crucial
units, will relieve nurses of the multiple complications that may arise from
their jobs, and ensure patient satisfaction by allowing them to deliver the
highest quality of care.

 

References

A
Day in the Life of a Nurse. (2017, June 26). Retrieved November 05, 2017, from https://www.ameritech.edu/blog/a-day-in-the-life-of-a-nurse/

Aiken,
L. (2008). Economics of Nursing. Policy, Politics, & Nursing Practice,
9(2), 73-79.

Arevalo,
J. D. (n.d.). RN-to-Patient Hospital Staffing Ratios Update. Retrieved November
19, 2017, from
https://www.amnhealthcare.com/latest-healthcare-news/rn-to-patient-hospital-staffing-ratios-update/

Bureau
of Labor Statistics, U.S. Department of Labor, Occupational Outlook
Handbook, Registered Nurses, on the Internet at https://www.bls.gov/ooh/healthcare/registered-nurses.htm

Emergency Department Visits. (2017,
May 03). Retrieved November 17, 2017, from
https://www.cdc.gov/nchs/fastats/emergency-department.htm

 

Ericksen,
K. (2016, August 3). The Nursing Debate: 8-Hour Shifts vs. 12-Hour Shifts.
Retrieved November 06, 2017, from http://www.rasmussen.edu/degrees/nursing/blog/nursing-debate-8-hour-shifts-vs-12-hour-shifts/

Safe-Staffing
Ratios: Benefiting Nurses and Patients. (2016, May). Retrieved November 18,
2017, from

Safe Staffing: Critical for Patients and Nurses

Total
Number of Professionally Active Nurses. (2017, May 01). Retrieved November 05, 2017,
from
https://www.kff.org/other/state-indicator/total-registered-nurses/?currentTimeframe=0=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D