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.