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How Nurse Staffing Ratios Impact Patient Safety, Access to Care

As industry professionals debate nurse staffing ratios, questions about patient safety, care quality, and care access abound.

A Massachusetts ballot question has the healthcare industry debating nurse staff ratios and how they can impact patient safety and patient access to care.

The ballot question at hand involves An Act relative to patient safety and hospital transparency (The Patient Safety Act), proposed by the Committee to Ensure Safe Patient Care. The question will appear on the November 2018 ballot and could enforce mandatory nurse staffing ratios.

Specifically, the proposal calls for enforced patient to nurse ratios in different departments in hospitals. These ratios will differ depending upon the department. For example, hospitals would need to adhere to a one-to-one nurse-to-patient ratio in intensive care units, while the emergency room would call for a one-to-three nurse-to-patient ratio.

The ballot question will also provide flexibility for hospitals that have unique patient needs, leaving ultimate decisions for enforced ratios up to the judgement of the nurse providing patient care, said the Massachusetts Nurses Association, one of the ballot questions primary proponents.

Nurses who are in charge of too many patients run the risk of becoming stressed out and making medical mistakes as a result of a hectic patient panel, according to the Committee. A 2018 survey commissioned by the Massachusetts Nurses Association found that nearly three-quarters of RNs believe nurses are assigned too many patients at one time.

Ninety percent of nurses say they don’t have the time to provide adequate comfort and emotional support to their patients and patients’ family members, and 86 percent of nurses say they can’t spend as much time on patient education as would be ideal.

“This has been a long time coming, and nurses have been advocating for a YES for patient safety for decades,” Donna Kelly-Williams, RN at the Cambridge Hospital Birth Center and President of the Massachusetts Nurses Association, said in a statement announcing the ballot question. “As an active bedside nurse, I see it every day on the hospital floor and I hear it every day from my colleagues across the state. It’s time for hospital executives to put patient care over profits.”

But the issues of patient safety, patient care access, and nurse staffing ratios are not always simple. While proponents of the Patient Safety Act state that enforced nurse ratios will improve patient care quality because nurses will divide their attention among fewer patients, critics say it could limit patient care access.

However, if a hospital or a clinic can only dedicate one nurse to a limited number of patients, it may hinder the hospital’s patient volume, according to the Coalition to Protect Patient Safety, which opposes the ballot measure.

“To implement this costly unfunded proposal, hospitals will be forced to make deep cuts to critical programs, such as opioid treatment and mental health services,” the Coalition says on its website. “Many community hospitals will not be able to absorb the added cost and will be forced to close.”

What are the pros and cons of nurse staffing ratio mandates? And what are the implications for this rule across the country?

Improved patient care quality, patient safety

Foremost, nurse staffing ratios and patient maximums are a question of care quality. Advocates for enforced ratios say patient safety and care quality suffers when nurses take on too many patients.

A 2017 study published in the Annals of Intensive Care found that higher nurse staffing ratios were tied to decreased survival likelihood. The analysis of 845 patients found that patients were 95 percent more likely to survive when nurses followed a hospital-mandated patient-nurse ratio.

The Agency for Healthcare Research and Quality (AHRQ) has also acknowledged the link between nurse staffing ratios and patient safety.

“Nurses' vigilance at the bedside is essential to their ability to ensure patient safety,” AHRQ says on its website. “It is logical, therefore, that assigning increasing numbers of patients eventually compromises nurses' ability to provide safe care. Several seminal studies have demonstrated the link between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity, and even mortality as the number of patients per nurse increases.”

However, nurse staffing ratios may be more nuanced than that. AHRQ contends that other factors such as shift time, patient acuity, and other environmental factors influence patient outcomes, regardless of staff ratios.

A separate study published in BMC Nursing found that hospitals need to consider high patient traffic times using predictive analytics to adequately address the notion of nurse staffing ratios.

Limited patient care access

Mandating certain patient maximums or nurse staffing ratios could have consequences for patient care access, according to the Massachusetts legislation’s critics.

Research from Mass Insight commissioned by the Massachusetts Health and Hospital Association (MHA) found that mandatory nurse staffing ratios would have negative financial implications for hospitals while limiting patient care access.

“The data suggest that a one-size-fits-all statewide implementation will be a costly and poor allocation of resources, leading to greater inequity in the provision of care, less local access to healthcare, and reduced patient choice,” the report found. “Furthermore, hospitals may be forced to hire less experienced and educated RNs, which would likely offset any quality and safety improvements that the proposal’s sponsors believe would follow from MNSR adoption.”

MHA and the Coalition to Protect Patient Safety both state that there is little evidence that proposed nurse staffing ratios will impact patient care quality, asserting that data on the matter is limited and inconclusive.

A study published in the Journal of Hospital Medicine states otherwise, acknowledging that there are improvements to be made from enforced ratios. However, those gains may come with their own set of issues, the researchers said.

“Cross‐sectional studies have demonstrated a potential link between increased nurse staffing and better patient outcomes, but if a financially constrained hospital makes tradeoffs by restricting access to care and services or by diverting funds from other beneficial uses, on balance, mandated nurse staffing ratios may not be beneficial to patients,” the research team noted. “The potential for unintended but serious negative consequences exists if hospitals in the safety net are mandated to meet minimum nurse staffing ratios without adequate resources.”

Similar rules nationwide

California is currently the only state with statewide mandates for nurse staffing ratios, with Massachusetts potentially following in its footsteps come November.

But the issue of nurse staffing ratios has become a national conversation.

A pair of proposed bills have made their way to the House of Representatives and Senate for federal consideration.

Senate Bill 1063 would require hospitals to submit a plan for proposed patient limits to the Department of Health and Human Services (HHS). House Resolution 2392 would require the same.

However, both of these bills have died in their respective chambers.

That hasn’t quieted the national debate, however. Trade groups such as National Nurses United (NNU) advocate for smaller staffing ratios for the sake of improved patient safety.

The American Nurses Association (ANA) likewise advocates for regulated nurse staffing levels. ANA specifically says nurse staffing ratios and patient maximums should be the purview of nurses themselves and that any regulation must have flexibility depending on patient and clinic need.

“The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit,” ANA asserts on its website. “This approach aides in establishing staffing levels that are flexible and account for changes; including intensity of patient's needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources (ancillary staff, technology etc.). Establishing minimum upwardly adjustable staffing levels is statute may also aide the committee in achieving safe and appropriate staffing plans.”

The issue of staffing ratios will likely remain hot-button. Fourteen states have introduced some form of legislation mandating nurse staff ratios and patient maximums, and other have established ratios in individual departments.

Going forward, healthcare professionals must understand how nurse staffing ratios will impact the patient experience, care quality, and care access.

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