By Michael Wong, JD (Founder & Executive Director, Physician-Patient Alliance for Health & Safety)
Our healthcare system is not safe without nurses.
The COVID pandemic underscored the need for nurses. Reporting for the Kaiser Family Foundation, Nancy Ochieng, Priya Chidambaram, and MaryBeth Musumeci write:
The disproportionate impact of the COVID-19 pandemic on nursing facility residents and staff has brought increased attention to long-standing workforce issues that can affect care quality and safety, such as staffing shortages and high turnover rates.
The Role of Nurses in Patient Safety and the Quality of Patient Care
The role of nurses may be often underestimated – doctors are the ones who diagnose illnesses, perform surgeries, and prescribe medications; and nurses are often just seen as order takers. However, this “brain and hands” analogy oversimplifies the relationship between doctors and nurses:
One way to look at the relationship between doctors and nurses is to think of the doctors as the brain and the nurses are the hands. The doctor studies the patient, then analyzes their problems and finds a solution. The nurse carries out whatever treatment the doctor says is needed, whether it’s drawing blood, fixing meals or working with medical equipment.
That doesn’t mean nurses are sheep who blindly obey the doctor’s commands. Nurses deal with patients up close, often more than the doctor. If a patient passes from one specialist to another, the nurse on the case may see the patient longer than either doctor. As a result, the nurse may have more insight into how the patient is doing over time. A nurse practitioner may assume several of the doctor’s functions, such as diagnosing a patient and writing orders.
Moreover, the importance of nurses was particularly highlighted when over 7,000 nurses went on strike at two major New York hospitals – Mount Sinai Hospital and Montefiore Medical Center. The reason for the strike – nurse-to-patient staffing ratios. The nurses’ union said that “it was forced into the drastic step of striking because of severe understaffing that left nurses caring for too many patients.” The strike ended after the hospitals agreed to hire more nurses.
Nurse-to-Patient Ratios are a Patient Safety Issue
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.
For more on nurse-to-patient ratios, please read the article, “Nurse-to-Patient Ratios are a Patient Safety Issue.”
Should Nurse-to-Patient Ratios Be Mandated by Legislation?
In the United States, federal regulation 42CFR 482.23(b) requires hospitals certified to participate in Medicare to “have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.”
However, this federal regulation leaves it up to each state to determine the exact ratio of nurse-to-patient. 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.
California is the only state to define the ratio:
Patient Safety is the Cornerstone of High-Quality Healthcare
The mark of a high-quality healthcare system is patient safety. After all, how good is our healthcare if it subjects its patients to high rates of morbidity and mortality? As Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., F.A.A.N., F.A.H.A. (Elizabeth S. Soule Distinguished Professorship of Health Promotion, University of Washington School of Nursing) writes:
In the past, we have often viewed nursing’s responsibility in patient safety in narrow aspects of patient care, for example, avoiding medication errors and preventing patient falls. While these dimensions of safety remain important within the nursing purview, the breadth and depth of patient safety and quality improvement are far greater. The most critical contribution of nursing to patient safety, in any setting, is the ability to coordinate and integrate the multiple aspects of quality within the care directly provided by nursing, and across the care delivered by others in the setting.
Nurses are a crucial part of any hospital’s efforts to improve patient safety. Nurses have the most direct interaction with patients of any healthcare professional—they consistently monitor patients’ conditions, administer medication, and communicate self-care and discharge information. Because nurses are directly involved with patients on a day-to-day, often hourly level, improving their ability to provide accurate, high-quality care is paramount to the success of any holistic patient safety strategy.