The issue of mandatory nurse-patient ratios is a widely controversial topic with many stakeholders in the issue, including nurses, patients, physicians, unions, nursing organizations, and researchers.  The first state law mandating nurse-patient ratios was passed in the state of California, USA in 1999, and implementation began in 2004.  The California Assembly Bill 394 identified a specific nurse-patient ratio number for each specialized area of the hospital. The objective for this law was that it would improve patient outcomes and ease the nursing shortage, and also that it would reduce nursing burnout and dissatisfaction.

 

In general, researchers view adverse outcomes as indicators of a nurse-patient ratio problem. Relying on less educated, less skilled staff in more numbers in patient care leads to increased adverse incidents and increased length of stay. This is a burning issue as nurse-patient ratio and appropriate skill mix seems to have a direct proportional relationship with patient outcomes.  Inadequate or inappropriate staffing can affect patient outcomes, patient safety, and the quality of care. Studies have shown that with adequate staffing, fewer patient deaths occur and patient outcomes are generally improved. (Unruh, 2008).  Studies also show that with adequate staffing, nursing turnover rates and burnout are decreased. 

 

In USA,  the Centers for Medicare and Medicaid Services has created new regulations connecting payments to patient outcomes.  Certain conditions such as catheter-associated urinary tract infections, that create increased healthcare costs, are no longer reimbursed.  When staffing is inadequate, more preventable problems tend to occur and, ultimately, the hospital will suffer due to these reimbursement changes. In India, we are not far away from outcome linked reimbursement. With all of these issues intertwined, it is important for solutions to the nurse-patient ratio issue to be discovered (Tevington, 2011). However, in reading various articles and learning about both sides of the issue, the question remains whether mandated nurse-patient ratios offers a solution or creates more issues in the goal of quality, affordable healthcare.

 

Research supports that adequate staffing and a balanced workload leads to better patient outcomes, higher nursing retention and greater organizational profits. The economic factors of nurse-patient ratios are many, and they are positive as well as negative. In order to accommodate the hiring of additional nurses, hospitals in California had to make some changes. For example, they decreased the number of ancillary staffs to help offset the additional cost of adding nurses to the workforce. This, in turn, created more work for the nurses, requiring them to perform the duties which had previously been assigned to the ancillary staff. Some hospitals had to decrease money spent on supplies and equipment, put renovation and upgrade plans on hold, and decrease opportunities for tuition reimbursement (Welton, 2007). On the other hand, a study by Rothberg, Abraham, Lindenauer, and Rose (2005) discussed the cost effectiveness of mandating the nurse-patient ratio. By decreasing the length of hospital stays and preventing hospital acquired infections and injuries, the potential savings for a hospital could be significant (Rothberg et al., 2005).

 

Even knowing that the nursing staffing level can affect patient outcomes, it is not an easy task to increase the number of nurses. One key problem is the increasingly higher acuity of patient care and the nationwide gap between the larger number of available positions and the smaller number of qualified registered nurses.

 

The nurse-patient ratio issue is certainly complex. Bill 394, which passed in California to mandate nurse-patient ratios, was an attempt to respond to many current healthcare issues. With rising healthcare costs, increased patient acuity, and less experienced individuals caring for the patients, there is concern about the quality of medical care patients are receiving. There are numerous articles discussing the advantages and disadvantages of mandated nurse-patient ratios.  One study by Lang, Hodge, Olson, Ramano, and Kravitz (2004) looked at the effects of nurse staffing on the hospital, patient, and nursing employees. The Joint Commission on the Accreditation of Healthcare Organizations and the Agency for Health Research and Quality have linked lower nursing staff levels with an increased risk of hospital-associated and hospital-acquired infections. According to the American Nurses Association (ANA ) (2010a), determining appropriate nursing staff and patient ratios is problematic due to budget problems, nursing shortages and a lack of data for guidance. It is believed that implementing legislation with a narrow focus does not empower nurses to use their specialties for the best patient outcomes and fails to make health care facilities accountable (ANA 2010b; De Vandry & Cooper, 2009). However, the ANA supports legislation with recommended guidelines for establishing nurse staffing based on critical factors e.g. census, patient acuity, nursing experience, and available supportive resources.

 

The obvious political strategy is state-mandated nurse-patient ratios, like Bill 394 which passed in California.  This bill mandates a minimum staffing number for different areas and specialties. One political strategy proposed by the ANA to help the staffing issue involves reimbursement. Currently, nursing care is not specifically reimbursed where the cost of nursing care is included in the room charge and is simply based on an average of the time and costs of patient care. The ANA proposes that if nursing care was changed from a cost center to a revenue center, this could significantly impact the relationship between the nurse and the hospital. If nurses were able to document their economic value with research data and change to a revenue center, this could allow for an accurate account of the hours and the cost of nursing care. This particular strategy could offer a good alternative to mandated nurse-patient ratios. 

 

Conclusion

 

To combat this issue a mandatory law, the nursing profession needs to be proactive, compliant, and adhere to the recommended nurse patient ratio as per patient acuity. Also, involvement in nursing lobbying will vocalize the problem in journals, legislations, political decisions, etc. 

 

Nurses always act as advocates for their patients, but they need to also advocate for themselves and the nursing profession. Nurses need to work collaboratively with other stakeholders to increase their support and promote quality nursing care. Finally, last but the most important, is that the nursing profession must obtain political knowledge and power by gaining the support of other powerful special interest groups (eg. American Medical Association) to ensure their employers which will held them accountable for obligations imposed on them by government laws (Tevington, 2011).

 

References

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Lang, T. A., Hodge, M., Olson, V., Ramano, P. S., & Kravitz, R. (2004). Nurse–patient ratios:  A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34(7/8), 326-337.

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Rothberg, M. B., Abraham, I., Lindenauer, P. K., & Rose, D. N. (2005). Improving nurse-to-patient staffing ratiosas a cost-effective safety intervention []. Medical Care, 43(8), 785-791. Retrieved from http://vwvw.massnurses.org/files/file/Legislation-and-Politics/Cost_Effectiveness_Study.pdf

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Unruh, L. (2008). Nurse staffing, and patient, nurse, and financial outcomes. American Journal of Nursing, 108(1), 62-71. doi: DOI: 10.1097/01.NAJ.0000305132.33841.92

Welton, J. M. (2007). Mandatory hospital nurse to patient staffing ratios: Time to take a different approach. The Online Journal of Issues in Nursing, 12(3). doi: 10.3912/OJIN.Vol12No03Man01