By Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety)
Nurse-to-Patient Ratios are a Patient Safety Issue
As this month is National Nurses Month, I have been thinking about nurse-to-patient ratios.
Why are nurse-to-patient ratios important?
A 2015 Press Gainey report, “Nursing Special Report: The Influence of Nurse Work Environment on Patient, Payment and Nurse Outcomes in Acute Care Settings” found that hospitals with better nurse staffing and work environments tend to have fewer readmissions for heart failure, pneumonia, and myocardial infarction. Says the Press Gainey report:
Staffing and work environments influence the efficacy and the efficiency of nurses’ delivery of discharge instructions that ensure patients understand how to care for themselves and when to seek medical attention post discharge. These instructions are critical to reducing readmission rates and must be provided throughout the patient stay … Although readmission rates are generally lower when staffing is better, the nurse work environment has a significant positive impact on readmissions, even in settings with lower staffing scores.
So, how do you improve nurse-to-patient ratios?
Nursing Shortage Crises Hurts Nurse-to-Patient Ratios
In a recent letter to Xavier Becerra, Secretary of the Department of Health and Human Services, the American Nurses Association (ANA) calls for concrete actions to address the current crisis-level nurse staffing shortage that puts nurses’ ability to care for patients in jeopardy. The ANA letter cites reports of nursing shortages across the United States:
- Mississippi has reported that it has seen a decrease of 2,000 nurses since the beginning of 2021.
- Hospitals in Tennessee are operating with 1,000 fewer staff than at the beginning of the pandemic, prompting them to call on their National Guard for reinforcements.
- Texas is recruiting 2,500 nurses from outside the state, a number that still will fall short of expected demand.
The COVID pandemic has exacerbated the nursing shortage:
Even before the COVID-19 pandemic, health care leaders warned that hospitals face a nursing shortage. The repeated surges of COVID-19 have made the situation dire, in part due to nurse burnout and moral distress. In a survey of more than 6,500 critical care nurses released in September 2021 by the American Association of Critical Care Nurses, 92 percent of respondents reported that the pandemic had “depleted nurses at their hospitals, and, as a result, their careers will be shorter than they intended.” Sixty-six percent said they were considering leaving the profession because of their COVID-19 experiences; and 76 percent said that unvaccinated patients “threatened nurses’ physical and mental well-being.”
However, the solution to improving nurse-to-patient ratios is not as easy as simply hiring more nurses. As Deena Kelly Costa, Ph.D., R.N., and Christopher R. Friese, Ph.D., R.N. of the University of Michigan School of Nursing point out, improved work conditions are a key component to addressing the nursing shortage issue:
U.S. nurses reported pervasive unsafe working conditions before the pandemic and have cited a range of stressors and traumatic experiences during it. Pressures on the nursing workforce may only worsen as Covid-19 subsides.
Is Legislation the Answer To Improving Nurse-to-Patient Ratios?
Mandating what healthcare professionals should and should not be doing is an issue that I have debated in the past, whether that be about making all hospitals electronically monitor all patients receiving opioids, raising the smoking age to 100 years old, or stopping the opioid epidemic.
So, is legislation the answer to improving nurse-to-patient ratios?
Even though better nurse-to-patient ratios have been shown to improve patient safety and outcomes, only one state (California) has enacted nurse-to-patient legislation. Eight states—Connecticut, Illinois, Minnesota, Nevada, Ohio, Oregon, Texas, and Washington—have legislation in place for hospitals to implement staffing committees or have the chief nursing officer develop staffing plans.
Moreover, although federal legislation has been re-introduced by US Sen Sherrod Brown (D-OH) and Rep Janice Schakowsky (D-IL) that would mandate minimum nurse-to-patient ratios at hospitals across the country, this legislation has not been passed into law.
Conclusion: Improving Nurse-to-Patient Ratios is Complex
Numerous studies have shown that addressing nurse-to-patient ratios will help improve patient safety.
However, the American Hospital Association (AHA) reminds us that nurse-to-patient ratios may be a more nuanced process than simple numbers. As Robyn Begley, DNP, RN, NEA-BC, FAAN, (Chief Nursing Officer and Senior Vice President of Workforce, ANA) explained:
Safe staffing is based on a complex set of variables such as hospital type, patient population, care delivery models, unit layout, patient acuity, and the education and experience of the nurse. Mandated nurse staffing ratios imply a ‘one size fits all’ approach to patient care. Nurse leaders and nurses are best qualified to determine appropriate staffing for the needs of their patients. Mandated nurse staffing ratios are a static and ineffective tool that do not ensure quality care, optimal patient experience, and staff well-being.
Improving nurse-to-patio ratios requires a number of issues to be solved. As the American Nurses Association proclaims:
Harnessing the full power and promise of nurses and the nursing profession depends on addressing complex issues such as:
- Building an adequate supply of nurses;
- Creating Safe, empowering, and healthy work environments;
- Public policy that supports quality health care;
- Laws and regulations that enable nurses to practice at the full extent of their education and licensure.
However, just because something may be hard to do, it does not mean it’s not worth doing – your life or the life of someone you care about could depend on it.