Finally, the Real Scoop About Staffing Ratios

For over a decade now, nurses in Massachusetts and other states have been lobbying for legislation that would mandate safe nurse to patient staffing ratios for hospitalized patients. For these nurses the kind of safe staffing ratios enacted in California in 1999 and implemented in 2004 has been the benchmark. Industry groups like the Massachusetts Hospital Association (MHA) have insisted the California law has not helped patients and that the public should not support staffing bills in other states. Their message to patients and the public is “ trust us and we’ll look out for you.” In spite of dozens of studies documenting that contemporary hospital staffing patterns are linked to patient mortality and preventable complications – hospitals continue to insist that there is no need for either government mandated nursing workloads.

Well just in time for this year’s Nurses’ Week, a major research study has documented the direct connection between California’s staffing ratios and reductions in patient deaths and complications.

The study in question is entitled “Implications of the California Nurse Staffing Mandate for Other States” and appeared in Health Services Research – a prestigious scientific journal.…/Aiken.2010.CaliforniaStaffingRatios.pdf
Its authors include a rock star like line-up of the most prominent nursing workforce researchers in the world – like Principal Investigator Linda Aiken and co-investigators Sean Clarke, Joanne Spetz, Douglas Sloane and Linda Flynn. These highly respected academics are by no means mindless boosters of either ratios or the unions that have promoted them as a solution to widespread hospital understaffing. Yet these academics conclude that ratios save lives.

This conclusion is the result of a comparison of nursing workloads and patient outcomes in California and New Jersey, and Pennsylvania – states that have no limits on the nursing workload. California legislation mandates a one to five RN to patient load -on medical surgical floors and 1-4 on specialty floors like oncology. In fact, researchers found that many California hospitals actually had better nurse to patient ratios than were mandated by law. With California as the benchmark researchers collected data on the nursing workload and patient mortality in New Jersey and Pennsylvania. While 88% of medical-surgical nurses in California cared for five patients or less on their last shift, that was only true of 19 and 33 percent of medical-surgical nurses in New Jersey and Pennsylvania respectively.

In those states nurses, on average, care for one or two more patients per shift. Turns out that just one extra patient makes a very big difference. With California style ratios in force, the researchers concluded, there would have been 10.6 percent fewer surgical deaths in Pennsylvania and 13.9 percent fewer in New Jersey. Even managers and chief nurses in California agree that staffing ratios positively impact patient outcomes as well as nurse retention. Which is why the authors argue that “outcomes are better for nurses and patients in hospitals that meet a benchmark based on California nurse staffing mandates whether the hospitals are located in California.”

This research comes out at a particularly critical time for nurses and patient care. Because of the lingering recession, more RNs who left thr workforce because of exhausting patient loads have been forced back into active duty and hospitals been able to declare that the “nursing shortage” is over.. In reality, there’s still a problem because many institutions – like Boston Medical Center and Tufts –are using the economy as an excuse to lay off nurses.

Four years from now, just as RN baby boomers begin to retire in greater numbers, the Patient Protection and Affordability Act of 2010 will kick in. When it does, 31 million Americans who’ve gone without primary care and preventive services will suddenly get health insurance and many of them will end up in the hospital. Laying off nurses and increasing their workloads, –which hospitals are free to do in the absence of legally mandated staffing ratios– is no way to pave the way for this huge influx of patients. As hospitals administrators function more like bankers on Wall Street hedge fund managers, can we afford to let them go unregulated. What we also can’t afford is the persistent myth that ratios are not in effect today. In fact, hospitals already operate on the ratio system. It’s the get-away-with-whatever-you-can ratio system. Hospitals staff according to ratios now. These ratios, however, are determined neither by what the patient needs, or scientific evidence on the connection between nurse staffing and patient care and the ignorance of many in the so-called C-suite (CEOs, CFOs and COO’s) of the importance of nursing care.

The people who now determine how many patients a nurse cares for are the kind of people a nurse manager recently told me about. She was fighting for an appropriate budget for her nursing staff and wanted to staff with an appropriate nurse-to-patient ratio. Many of her nurses had been there more than five years. In her budget meeting, the CFO of the hospital, she said, insisted that ” a nurse is a nurse, is a nurse, is a nurse. A nurse who’s been in practice for more than five years brings no more added value than a new nurse, he insisted. With this kind of disinformation passing as fact it’s no wonder we’re in the situation we are in in health care and nursing.

Showing 15 comments
  • jothenurse

    I am a nurse and a nurse staffing coordinator in CA. Working with nursing supervisors, managers, charge nurses, and nurses throughout the hospital, all nurses are not equal. All things being equal, would I expect a new graduate nurse who has finished orienting on an orthopedic unit to provide the same care as a nurse with five years of experience on an oncology unit? Probably not. Does someone who knows the basics of preventing infection, pain management, and post-operative care (such as in a new grad) provide the same care as a nurse with 5 years of knowledge, skills, and experience treating patients undergoing strict chemotherapeutic regimen? Probably not. How much do I care? If the patient was my ailing mother, you bet your patootie it matters!

  • Disillusioned Dixie Nurse

    I got a letter a couple of weeks ago. It was a mass mailout to every nurse that worked at the hospital I work for. It was an anti-union letter riddled with veiled threats about layoffs and pay cuts and benefit cuts. I am very unsurprised. I’m keeping my head down and signing up quietly. My state is in dire need of a union, but nurses in my state are notorious for not standing up for themselves. I can only pray it happens.

  • Mary Ann Van Orden

    Do the staffing ratios in California regulate unlicensed personal? Even with only five patients I could not give proper care to my patients without a unit secretary or an aide. Patient care is truly a team effort.
    All the documentation is also a drag on our time. Pulling medications from a machine uses up 30-40 minutes of my day also. As always nurses are expected to do more and more with less.

  • Reply

    Here in Illinois nurses tend to be opposed to staffing ratios because the Illinois Nurse’s Association is against them. But I have to wonder how much of this is due to hospital lobby influence? Staff ratios are not bad here at Magnet hospitals but can be very rough in smaller hospitals – one smaller hospital I worked at had 6:1 ratios on a very busy, very sick telemetry floor that worked with multiple cardiac drips since the ICU was so small.

    But the argument here is that staffing ratios didn’t work in California, and that it creates absurd situations (like nobody can go to lunch, because that would mean a nurse was watching more than 5 patients!). I still don’t really buy it, and I’m glad to see your post.

  • Melissa Moore

    This is a really great article. I will do some research in my spare time. I will also forward this link to my direct supervisor. This has been my argument, especially in my last class. However, the instructor, who happened to be a judge, made a comment for me tone it down a little in my online classroom forum because I posted a message, in all caps and underlined that I wanted to know who was going to care for the millions of people that will suddenly have health insurance, when there is already a shortage.

    Melissa A. Moore, RN
    Join my Cause on Facebook!
    Nurses for Lower Patient to Nurse Ratio Over 32,000 members!!!

  • Rosemarie Brenner

    My mother was a nurse for over 30 years and her biggest disappointment was in not being able to provide the personal care she was trained to give as a young nurse. As time went on, the number of patients she had in her care simply made it impossible to spend the time necessary to provide the excellent care she prided herself on …. the very reason she became a nurse in the first place.

  • Rita Batchley

    Do ratios matter? Heck Yes. Scientific evidence supports nurse ratios, but the need for profit to pay CEOs and stockholder dividends is driving our hospital leadership to ignore and attack the data.

    My idea to advocate for medical justice has to do with a new healthcare hero, the bedside RNs of this country who are the safety nets for catching mistakes and malpractice before they happen.

    As technology changes medicine, it is even more pertinent that we have humans (trained RNs) at the bedside to monitor and assess patients.

    Rita Batchley RN, BSN
    Ventura, CA

  • Vickie Harris

    Although I am against nurses striking I have marched and protested as well as unionized . I believe the most traction we ever got came from legal actions and political activism. Having the public made aware of our overtime hours and working conditions REALLY made the difference !! People just didn’t know that we often worked 12-16 hours a day every day or many days. I’ve kept my pay stubs because many folks just don’t believe it unless they see it. As an Oncology certified RN on an inpatient unit with mostly level 3 and 4 acuity patients I had 16-18 patients daily with my LPN. Transfusing blood and flying one out while another went into DIC and yet another developed graft vs host post BMT was a nightmare. (all on one shift) We frequently hugged each other and cried at the end of shift and most left the unit after a year or so due to physical and emotional exhaustion as well as fear of losing either a patient or their license due to unsafe practice environment. Managers wanted more staff but admin couldn’t justify the cost ? Admin in health care is a different animal. The bottom line isn’t just about the $$. Donate your time and $$ to media awareness campaigns and legislative lobbying.

    • Suzanne

      I couldn’t agree with you more.

  • Di

    Does anyone know a website where hospital staffing ratios are published? I am trying to find if it is typical in CA to have 2 active laboring patients to one nurse. If I was a PG Mom this is something I’d want to know. Or a patient entering a hospital for any reason for that matter. I can’t seem to find any facts like that on the hospital websites etc, Thanx

  • judith Foley

    Nurses are not the same and the Ca ratio law is a step in the right direction. Patients are not the same and the piece missing is their acuity. I am a retired RN and was recently hospitalized in Ca. at a hospital where I was employed for 25 years. The ratios do not work when the patient acuity is not taken into consideration. The understaffing of my surgical admission led to a medical readmission . The understaffing and the uneducated unlicensed staff led to my discharge against medical advice. Appropriate nursing care and the ability of RN’s to follow post op orders would have prevented my horrific hospital experience. When nurses try to deliver appropriate care and work overtime to accomplish it, they are told they are working too slow. I never felt they were working too slow. Only that they were always out of time. I was a strong advocate for ratios and am heart broken to see what passes for inpatient nursing care. I am also angry and am going to attempt to change the systems glaring errors.

  • robyn smith

    Why isnt anybody talking about nursing boards and nursing associations? Nursing boards are sources of state revenue.Their actions masked by legislation claims of public safety priorities. And practice acts that legally withhold constitutional rights from those they “govern”.
    Nursing associations are NOTORIOUS for pushing for legislation that does nothing to advocate for nurses rights.
    Every change seems to dig a deeper hole of increased demands of absolute accoutability and liability to vague and broadly stated laws/codes/standards and “scopes.”
    Boards gain increasing powers to levy fines againsts nurses when they fail to adhere to these vague laws.
    Regardless of company policy, regardless of absolutely all other factors, the nurse is accountable.
    Factors that are as intangible as they are pervasive in our modern society.
    NURSES-you are NOT represented!
    Boards govern you with absolute authority, associations use you for your donations_to advance a political agenda-which wouldnt be so bad if it has some thought behind it.And employers can employ at will in some states-like mine.
    Nurses who escape the bedside to become activists and board members and managers are blind to the historical implications of the currnt system structure.
    The social implications of which are profound. Systemic crises that can be seen dissected right now in the media with regard to other and very similar governmental structures.
    Boards, agencies, commissions, departments, task forces….
    Each given authority to write their own by laws, rules, have their own judge and jury. And those who have run from the bedside findfreedom in the arms of these organizations. They honestly never look back. It is ignorance. It is pervasive. It is destructive of human rights and dignity.
    Until nurses have representation, it will not ever change.
    And I sincerely hope that anyone thinking about going into debt to become an RN will first get an some knowledge in civil/administrative law.
    I think they would likely avoid such a career.

  • Adelaide

    Very good post! We will be linking tto this great
    article on our website. Keeep uup the good writing.

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