A recent survey commissioned by the Massachusetts Nurses Association (MNA) showed that eight in 10 registered nurses believe hospital staffing levels are adversely affecting patient care. The MNA is pushing for state legislation that would establish nurse-to-patient ratios on various hospital units. As of now, California is the only state that has established such a law, but nursing unions are currently lobbying to get more states to enact nurse-to-patient ratio laws.
A related federal regulation—42 CFR 482.23(b)—has been in place for some time. It requires Medicare-certified hospitals to "have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses and other personnel to provide nursing care to all patients as needed." The regulation's vague wording has left it up to states to ensure patient safety through appropriate staffing. Unfortunately, there is little research on what the ideal ratios should be. How can hospitals ensure that they are setting the right staffing ratios?
What nurses are saying
Not all nurses believe fixed staffing ratios are a good idea. "You should be monitoring us for the quality of our care, not a fixed number," Joan Vitello-Cicciu, associate chief nurse in management at Brigham and Women's Hospital told WBUR's CommonHealth. According to Vitello-Cicciu, Brigham and Women's Hospital currently assigns nurses three to five patients based on the intensity of the patients' recovery. "And we adjust our staffing based on that," she said. "A face transplant is not the same as somebody recovering from a hernia."
Jolee Cochran, a registered oncology nurse at Cedars-Sinai Medical Center in Los Angeles told Kaiser Health News that the California law has made her job more manageable, especially given the higher acuity of today's hospitalized patients. But she also said it has made scheduling more challenging. For a nurse to go on break, "there has to be someone there to cover you," Cochran said. "By law, you can't fudge that or else you get fined."
What the literature says
A recent literature review that was published in the Annals of Internal Medicine found that although most published studies show there is a relationship between nurse staffing and mortality, there is no evidence of a causal relationship. According to the author, Paul Shekelle, MD, PhD, "lack of a published evaluation of an intentional change in RN staffing" from some initial value to a lower nurse-to-patient ratio "limits conclusions on increasing nurse staffing ratios as a patient safety strategy."
The Agency for Healthcare Research and Quality also published Shekelle's findings. That publication concludes that given the lack of an evaluation of a deliberate change in RN staffing, the strength of evidence for the finding that nurse staffing ratios are associated with reductions in hospital-related mortality is "moderate." AHRQ goes on to say it believes the strength of evidence for the relationship between nurse staffing ratios and other outcomes (e.g., hospital-acquired pneumonia, falls, pressure ulcers) is low.
Alternative strategies
According to the ANA, in addition to regulating nurse-to-patient ratios, state staffing laws tend to take one of two approaches:
-
Require hospitals to have a nurse-driven staffing committee to create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff
-
Require facilities to disclose staffing levels to the public and/or a regulatory body
The ANA tends to favor the first approach. On its website, the ANA says, "The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. This approach aids in establishing staffing levels that are flexible and account for changes."