7/18/2006
- Nurse-Recruiter.com
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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