Nurse Patient Ratios: A Cookie Cutter Won’t Fix The Problem

Staffing ratio debates have been going on for a number of years now.  States like California have already ratified such ratios but without adding any real teeth to the law.  Massachusetts has been battling for more than a year trying to get legislation passed.  So what are the issues, how does it impact nurses and nursing?  Whose counted, whose left out and why.

It’s a cinch that this problem is going to worsen as the shortage of nurses in the U.S. continues to rise compounded by the increased need for care (as the baby boomers reach later years and require more care).  A research study done a few years back showed that the vast majority of health care dollars are spent in the last year of life.  Included in that cost is obviously the cost of nursing care.

On one side we have some nursing organizations saying we must have laws that protect patients by requiring a certain number of nurses for every patient in the hospital (mind you they don’t seem to care about nursing homes, or other types of inpatient settings).  As a nurse, who no doubt has had an overloaded assignment, one might tend to quickly agree.  But there is a problem with this “simple solution”, it does not take in to consideration many factors including but certainly not limited to:  patient mix, patient acuity, patient education levels, and many more.  Now before you start writing me, let me say that even the ANA opposes some of the pending legislation for these same reasons.

Here’s an example of two different hospitals, but in the same state.  One is a large teaching hospital.  It’s filled with Interns and Residents, lots of new graduates and lots of students.  The hospital performs “cutting edge” care and has a very high acuity rating.  Its patients mix is comprised mostly of transfers and referrals too acute for other facilities.  Add to this they have patients from all over the world that go to this facility for care.  The other hospital is a small rural facility, it handles the fairly routine needs of the community.  All of the doctors are experienced, most of the nurses have been on the job for many years.  How do you come up with one solution that meets the needs of both of these hospitals?  The simple solution will not do.  You’ll end up with too few nurses in the teaching facility and too many in the small rural hospital.

That leads to another important consideration, the nurse’s level of training, experience and support.  Let’s say we have a fairly new grad, been on the job six months.  S/he is off orientation and expected to take a “full” assignment.  Does any nurse manager really think that new grad can handle the same load, as competently as the nurse whose been working on that unit for the past five years?  We must consider the staff as individuals, nurses are not equal in their capabilities.

Furthermore, to date, none of the legislation aims to solve the underlying problem …there is a nursing shortage and its going to get worse!  We need more educators, we need more seats in the schools of nursing.  Students need more clinical hours in more diverse settings.  So far, the numbers just are not adding up.

As healthcare professionals, nurses must also be aware of how this impacts the cost of care and the subsequent access to care for the general public.  Let’s take our example hospitals above.  If we add a simple nurse-patient ratio law, it is unlikely to impact the teaching hospital but is likely to have a very detrimental effect on the smaller rural hospital.  It will drive up costs, these costs are passed on to insurance companies, states, and individuals.  When the cost of health care is inaccessible, we know people avoid it even if they’ve identified they need care…they wait.  So when we advocate a simple staffing ratio, we may indirectly be doing harm to those we are here to protect.

Okay, we do need legislation that is going to prevent for profit companies from understaffing, but the solution is not a simple staffing ratio, one size fits all.  Nursing is too complex a science and service to be handled by cookie cutter legislation.  Any legislation that does not put staffing in the hands of the nursing staff at a facility is going to miss the mark.  That’s right, nurses must be in charge of saying how many patients are assigned to a particular nurse.

Let’s also consider, as I have written many times in the past the old model of team nursing.  Some hospitals are trending back that way again.  But there is a preference to use unlicensed assistive personnel (UAP).  These are individuals that the hospital, at its sole and unreviewable discretion has determined competent to help provide nursing care.  In many cases, “skilled” nursing care.  It is high time we recognize the nearly 1,000,000 LP/VNs in the U.S. and their history.  Since World War II, the LPNs in this country have stepped up to the plate during every nursing crisis and helped to provide the much needed skilled nursing care our citizens need and deserve.  Registered nurses should be demanding that if they work in a team environment, it should be with licensed nurses that have been through accredited programs and been licensed by the state to meet a minimum competency level.  This is a no brainer and the CA legislation on nurse patient ratios includes the LVN in the mix.  The California Nurses Association fought hard to prevent the inclusion of LVNs in the mix, but the fact is that LP/VNs are far better suited to help alleviate the nursing shortage than are UAPs.  See the research article above by Dr. Jean Ann Seago for more on this subject.

So what’s the answer?  The nursing professional organizations in conjunction with healthcare providers should immediately seek funding and research the best way to address this issue.  We have been moving towards evidence based practice for many years.  We should not make staffing an exception to this rule.  There has been one minimal study done on the subject RN staffing ratios and it is quoted often during these staffing battles.  The authors sited many limitations in this study and it only showed nursing had an impact on four areas of inpatient care and the biggest result of the study was areas where additional research needed to be conducted.

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