Nurse ratios in practice

Some states have already adopted mandated ratio policies, but there is an ongoing debate, particularly in nursing professional forums, concerning whether it is suitable, acceptable, financially viable, and even beneficial to patients. My partner at In-House Health , Ari Brenner, covered the current state of the legal status of ratios in a recent piece that addresses the recent history and the arguments for and against them.

But how does that really work out for the nurses? To be honest, I considered myself to be an advocate of mandatory staffing ratios, but after doing some research I must say, the reality is more complex.

Let’s look a bit into the idea of mandatory staffing - the principle behind it is very simple:

The goal of staffing ratios is to ensure patients get the care they deserve. When there are limits to the number of patients in a nursing workload, nurses can spend more quality time with patients. Nurses can assess status changes and attend to patients' needs better.[1]

Depending on a hospital systems’ nursing structure, often related to the presence of a nurses’ union, mandated nurse to patient ratios can be implemented. Ideally, this structure ensures that nurses are not overrun with more patients to care for than expected, quality of care is increased due to a decrease in the number of patients per nurse, and staff experience greater satisfaction and less burnout.

A 2018 survey — conducted by NursesTakeDC, a group that lobbies for stricter nurse-to-patient ratios and analyzed by University of Illinois researchers along with the Illinois Economic Policy Institute — found that only 20% of nurses in the United States feel staffing levels are safe.[2]

In general, it will probably not shock anyone to hear that: 9 in 10 nurses believe the quality of patient care often suffers due to nursing shortages. 6 in 10 blamed staff shortages as to why they don’t have control over their careers. 65% say there is not enough staff. 56% have noticed their patients have suffered because they have too much on their plate.[3]

As a former ICU nurse, shift manager, and clinical instructor, I can confirm that staffing ratios can have a significant impact on your work.  I remember intensive shifts when I had to manage the ICU and its staff, combined with students shadowing me, and my own 2 ICU patients to care for. The minimum critical care assignment was two patients per nurse. To properly manage the shift and give enough attention to the students, I would expect (on student days) not to attend to patients, or at least to have only one under my responsibility. It is difficult to concentrate when spread across so many different tasks. Patients' care is always a top priority, but there is a lack of ability to devote attention to academic and managing duties. The combination of 11 beds of ICU management creates a significant emotional and physical strain by itself.  After my scheduled shift time, I had to stay after just to finish charting and other (mostly bureaucratic) tasks.

One instance stands out to me: it was a rare case when I wasn't working in the ICU, but in medical/surgical, which manages the care of patients who have less intense clinical needs. During the night shift, I was the shift manager and only had a nursing assistant to accompany me. I still recall this shift because as the only RN staffed for 21 beds, I had to explain to a patient that he had been selected to be transferred to another department, all while not even sharing the same language to have this conversation. While this difficult back and forth continued, I did not have any backup to cover care for the other patients.

On the contrary, sometimes I was the ICU shift manager and I would immediately know that it was overstaffed (either the patients are a familiar case with straightforward care, or suddenly there is an empty bed or two). Sure, such a situation looks great at first glance, yet I always knew that it would be better to release somebody home from the shift (voluntarily) and re-assign remaining patients to those staff members who would stay. There were always nurses who would jump on the opportunity to go home and get some rest!

So, what the nursing staffing regulation truly mean?

• Safer working conditions: By limiting the number of patients a nurse can oversee, there is less margin error for nurses.
• Higher pay: Staffing ratios create a safer workplace, which leads to nurse retention. National Nurses United found that staff turnover is significantly lower in states with mandated ratios than in states without regulation.
• Greater transparency: Healthcare leaders who commit to safe staffing ratios promise to value nurses.
• Better work life balance: managers are accountable for adequate staffing each shift and as a result there is less pressure to cover short shifts.[4]

The best way to sum up the pros of mandatory staffing ratios is to cite Gerard Brogan, who worked as a registered nurse in California since the late 1980s regarding the law passing in California in 1999:“Nurses are much happier in their work,” Brogan said. “They can now give the kind of care that they were trained to do, that their ethical push says they should do, as a registered nurse and as a patient advocate, and there’s less burnout.”[5]

But is there a different side to this story?

Janet Haebler, a senior associate director for policy and state government affairs at the American Nurses Association has a different opinion: Putting ratios into law, Haebler said, robs nurses of the flexibility — and the independence — they need when it comes to staffing. “The number of patients for whom a nurse cares is not a true measure of the work that is involved,” Haebler said.

I personally could not agree more.

In a paper published by the District of Columbia Hospital Association, it is asserted: mandatory nurse ratios are not the answer. Among many other claims, here are the ones that directly impact nurses[6]:

Loss of autonomy and flexibility

“The combination of meal break and staffing regulations was perceived as reducing the ability of staff nurses to use their professional judgment in determining the best time to take a break, and interviewees believed that nurses found this loss of autonomy frustrating.” – California HealthCare Foundation, 20091

“Our findings suggest that nurse staffing models that facilitate shift-to-shift decisions on the basis of an alignment of staffing with patients’ needs and the census are an important component of the delivery of care.” – New England Journal of Medicine, 20114.

Lower job satisfaction

“Passage of this [California] legislation led to changes in nurse staffing levels; RN workloads increased, and RN job satisfaction decreased.” – MEDSURG Nursing, 20112

More work

“A reduction in ancillary staff support was reported at several of the [California] hospitals. These reductions resulted in additional primary care duties for the RNs, such as giving baths to patients. Hospital managers reported hearing from their RN staff that they were unhappy with these additional job tasks and the shift in their role in patient care.” – California HealthCare Foundation

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Staffing is a complex issue composed of multiple variables, mandated staffing ratios, which imply a ‘one size fits all’ approach, cannot guarantee that the healthcare environment is safe or that the quality level will be sufficient to prevent adverse patient outcomes.

The best practices for nurse staffing

The truth is more nuanced after looking at the advantages and disadvantages of mandated staffing. The work of nurses as a fundamental component of any healthcare system is intricate. Focus should be on giving nurses adequate support and resources, using valid and reliable staffing indicators, adjusting staffing levels to patient complexity and acuity, giving nurses the support and resources they need, and routinely evaluating and improving staffing outcomes. Things that can at least partially be accomplished by technological tools.

The bigger picture: how do ratios tie to what else nurses want from their work?

Among things Gen Z, millennial nurses want from their hospitals we can find mentions of [7]:

Respect and recognition: Jennifer Gil, MSN, RN says: "Nurses need to feel valued, respected, and prioritized. More than anything, nurses want to feel safe and valued in order to best care for their patients."

Improved working conditions: Change must come in all forms. Employers need to get creative and transform outdated staffing models that no longer work.

‍More flexible working hours: Shantelle Cruz, a nurse at Broward Health North in Broward County, Fla. "We are looking to be able to choose our own schedules and which hospitals we work for. Having multiple options for how we want to work is so helpful.

Long-term workforce solutions: nurses are lacking long-term staffing and overall workforce solutions to help mitigate the stresses the pandemic has brought to the health care system.

On a personal note

Having spoken with current direct care nurses that support our technology in In-House Health, I learned that a primary career goal has remained accomplishing a healthy balance between work and personal life - most of which has not been feasible in roles at the bedside due to the strain of being short-staffed. Without a standard nurse-to-patient ratio, the demands of a shift outweigh the productivity of time off from work; for example, the stresses of a high nurse-to-patient ratio leads to the inability to provide even the most basic of physical needs during a shift, affecting proper sleep and nutrition which leaves a nurse exhausted outside of working hours. When a nurse feels burnt out by a high-stress job, personal relationships experience tension.

Another highly sought-after career goal describes flexible planning. When a nurse works in a short-staffed environment, flexible scheduling becomes obsolete, often resulting in higher staffing ratios and even mandatory overtime during extreme challenges.

What do all of these have in common?

I think that the connection that ties them together is effective workforce management. Because, hey, we all know, there is no incentive or perk that will make nurses as excited to come to work as an adequately staffed unit or floor.

Nurse to patient ratios are implemented in an effort to provide optimal care, combat overworking the nursing staff, and improve nurse job satisfaction. On paper, nurse to patient ratios is preferable, but logistically the implementation can be difficult and provide new issues.

Conclusion

To address workforce management needs, healthcare facilities and organizations must identify the staffing model that works best for them. Once the right model has been identified, the next step is implementing it. Unfortunately, that task is often easier said than done.

Building and rolling out an effective workforce management strategy is a complex process, and if it isn’t properly managed, it’s unlikely to be a successful one. That’s why many hospitals and healthcare organizations have implemented software-based workforce management solutions.

Using these solutions, healthcare organizations can proactively address workforce management needs, rather than waiting until these needs affect patient care and clinical outcomes.

Organizations can use workforce management software to proactively plan as well as react faster and more effectively to unexpected changes, such as scaling staffing up or down as needed to ensure the available clinical resources match patient demand in terms of patient census and intensity of patient care.

References

1. https://nursejournal.org/articles/benefits-nurse-to-patient-staffing-ratio-laws/
2. https://whyy.org/segments/why-mandated-nurse-to-patient-ratios-have-become-one-of-the-most-controversial-ideas-in-health-care/
3. https://www.connectrn.com/industry-insights-2022
4. https://nursejournal.org/articles/benefits-nurse-to-patient-staffing-ratio-laws/#:~:text=With%20mandated%20staffing%20ratios%2C%20nurses,compliant%20with%20programs%20like%20HRRP.
5. https://whyy.org/segments/why-mandated-nurse-to-patient-ratios-have-become-one-of-the-most-controversial-ideas-in-health-care/
6. https://www.mnhospitals.org/Portals/0/Documents/policy-advocacy/nursestaffing/130219%20DCHA_FactSheets.pdf
7. https://www.beckershospitalreview.com/nursing/10-things-gen-z-millennial-nurses-want-from-their-hospitals.html#:~:text=%22Nurses%20need%20to%20feel%20valued,best%20care%20for%20their%20patients.%22

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