Nurses Promote Safe Staffing Ratios to Improve Patient Care and Nurse Retention

Kathy Quan RN BSN PHN - 03/18/19

Nurse-to-patient staffing ratios has been an issue for nurses since most of us can remember. The care delivery models have changed several times over the past 4 decades in an effort to reduce the harm produced by inadequate staffing. However, data continues to prove that shortages of nursing staff causes burnout (aka caregiver fatigue) for nurses and contributes to the morbidity statistics and outcomes for patients.

Nurses have been fighting the staffing ratio issue for decades, but the last time they took to the streets and marched in protest was in 1995. Thirty-five thousand nurses from all around the US took to the streets in Washington DC that year to bring attention to staffing cuts that were increasing nurse-to-patient ratios, unlicensed personnel being hired to replace registered nurses who were in very short supply, and the idea of reducing patient stays, especially for those critically ill all in an effort to reduce the skyrocketing costs of health care.

Third Leading Cause of Death

A 2016 study published by the British Medical Journal (BMJ) was conducted at Johns Hopkins Medical Center. The study concluded that if we utilized the CDC coding system to capture diagnostic errors, communication breakdowns, and poor judgement by burned out staff, and put this data on death certificates, we would prove that “medical errors are the third leading cause of death in the US today.”

There have been multiple studies for decades in the US and around the world that have proven patient mortality rates rise along with nurse-to-patient ratios. “Known as Registered Nurses Forecasting (RN4CAST), the study estimated that an increase in hospital nurses’ workloads by one patient increases the likelihood of in hospital death by 7 percent.” The study concluded that the average hospital has a 1:8 nurse-patient ratio, however, some nurses treated up to 18 patients at a time. 

Many of these studies have also concluded that when the number of BSN degreed nurses is increased, the patient mortality decreases. What all of these studies have shown nurses is that nurses need to stand together and support each other in the effort to improve quality of care and patient outcomes with safer staffing conditions. This will also help reduce nurse burnout and reduce many retention issues which add to the shortage of nurses and discourage men and women from becoming new nurses.

The huge hospital industry diligently lobbies and works against anything that affects their bottom line (revenue). As pay-for-performance, based on the quality of patient care and outcomes comes into play, we can hope that hospitals may begin to feel the problem in their pocketbook and search for answers beyond just placing blame on the overburdened nursing staff. Patient satisfaction surveys are turning to rating their experience of care which will shed more light on not just whether they were satisfied with their care and outcomes, but what was their experience like? What was quality care, and what technically sucked for them?

Nurses need to educate patients and the general public about patient care quality issues and mortality connected to nurse-to-patient ratios. Hospitals fight this by forbidding nurses to let patients and families know that they are short-handed or that the current situation endangers both patients and nurses. Nurses are the backbone of the health care industry and the largest workforce in the US. Nurses need to use their influence to bring this issue front and center to Congress and the American people.

 Frustrated, angry nurses organized and in April 2018, nurses once again took to the streets in Washington DC to protest unsafe staffing ratios and to bring attention to two bills that have stagnated in the Senate (S1063) and House of Representatives (HR2392) that would mandate minimum nurse staffing standards and safer practices.

Show Me Your Stethoscope

The grassroots organization Show Me Your Stethoscope re-energized the effort and organized the event #NursesTakeDC to march on Washington DC, hold rallies, and meet directly with legislators to educate them about these bills known as The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017and the need for safer practices. 

All nurses are encouraged to read up on these bills and talk to their legislators. As constituents, nurses can drive home the evidence (being mindful of HIPAA regulations) and need for support for these bills for patients in the hometowns these legislators represent. Find your legislators and contact them by email, tweet and/or phone. If you can get the name and email address or twitter handle of their health care staff it would be even more beneficial to direct your email to them as well. Find your legislator’s local office and arrange to meet with your legislators when they are home on breaks. Organize a group of nurses to go with you. Educate yourself about the legislative process and follow these bills through. Stay vigilant. Stand with your fellow nurses and support each other. Patient lives and your career depend on it.

Federal Law Ineffective

According to the American Nurses Association, Federal regulation has been in place for some time, 42 Code of Federal Regulations (42CFR 482.23(b)which requires hospitals certified to participate in Medicare to "have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed". 

This language is nebulous and does not come close to addressing or fixing the problem with safe staffing ratios. Nor does it help reduce retention problems for burned out nurses leaving the nursing profession. The Robert Wood Johnson Foundation cited in 2014 that 1 in 5 new grad nurses left the nursing profession within the first year of licensure and 1 in 3 left within the first 2 years of licensure! New nurses are walking away. It is vital to the nursing profession to take steps to improve patient care and work conditions to retain new (and all) nurses. Continuing education for nurses has been shown to improve the quality of patient care and outcomes and help older nurses compete with new grads who bring more current knowledge to the table. But this is only part of the solution.

States Support Staffing Ratios

While several states (CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WAhave shown support for safe staffing ratios, as of 2017, only California has passed safe staffing ratio law. Massachusetts has been trying hard to get their safe staffing bill passed and 7 states (CT, IL, NV, OH, OR, TX, WA)have passed legislation requiring safe staffing committees in hospitals.

The California Nurses Association worked diligently for 13 years despite efforts from the powerful hospital industry to lobby and advocate for this legislation and finally get it passed in 2004. It was hoped that other states would soon follow suit, but despite support, to date, no other legislation has passed. The current bills before Congress are based on the California legislation because California has been able to document the successful outcomes from passing this law. In 2010, a Health Services Research study concluded that the California legislation has resulted in improved patient outcomes as well as retention of nurses.

In 2014, the study conducted by the Agency for Healthcare Research and Quality found that quality of care would be improved, and length of stay reduced at no additional cost by increasing nurse staffing and skill mix.

Skill mix can be improved through continuing education for nurses and provides benefit to nursing staff as well as patient outcomes. Nurses can also find CE courses to reduce and/or prevent burnout which can help improve their individual experiences with the stress of high patient ratios.

The nursing workforce is the largest in the US and should be the strongest advocate for the profession as well as patient care. Get involved, educate yourself, and work to improve patient care and outcomes.