Introduction
There has been an ongoing debate about whether the concept of mandatory minimum nurse-to-patient ratios has a positive impact on safer patient care and motivation of nursing professionals (Aiken et al., 2010). While some states in the U.S. have implemented the statutory ratios with the view to benefiting from the many perceived advantages (e.g., safer patient care, more manageable workloads, enhanced job satisfaction, superior recruitment and retention of nurses), many others seem unready or unwilling to implement the ratios due to varied reasons (Shekelle, 2013). This paper reviews available nursing scholarship on nurse staffing ratios with the view to synthesizing the reasons behind the failure of some states to implement minimum nurse-to-patient staffing ratios.
Problem Statement with Background
Problem
The problem relates to why some states in the U.S. seem unwilling to implement minimum nurse-to-patient ratios yet the concept has been associated with positive patient care outcomes and increased job satisfaction for nurses. Currently, the implementation of statutory ratios is a prerogative of state governments and some states such as California have implemented the statutory requirements while others are still lagging (Aiken et al., 2010). It is important to understand the reasons behind the failure by some states to fully support the initiative to spur adoption.
Justification
There is growing evidence of the importance of adequate nursing levels at health care institutions and the need to have standards put in place across the country to ensure that more patients are being treated by a motivated nursing workforce that can deliver safe, reliable, and quality patient care (Aiken et al., 2010). However, many states across the country are yet to implement the statutory ratios, leading to poor patient care, an unmotivated workforce, high nurse turnover, and other adverse outcomes (Shekelle, 2013). The knowledge about the reasons behind failure to adopt minimum nurse-to-patient ratios is therefore critical in facilitating adoption, enhancing safer patient care, and minimizing dissatisfaction-oriented nurse turnover.
Literature Review
In their study on nurses’ perceptions of nursing staff ratios and new hospital payment regulations, Buerhaus, Donelan, DesRoches, and Hess (2009) found that the majority of RNs favor ratios though the support is not universal as some nurses think their workload will increase due to lack of more staffing. More nurses felt that the nurse staffing ratios should be mandated by the federal government rather than the respective states. The study also found that “RNs who reported low levels of satisfaction with their current job were significantly more likely to support mandates at the federal level than were RNs who reported they were satisfied with their jobs” (Buerhaus et al., 2009, p. 374). This study underscores the fact that nurse-to-patient ratios should go hand in hand with additional staffing to achieve the intended outcomes.
In another study, Chapman et al (2009) found that hospital leaders do not believe that ratios have an impact on patient quality of care and that it is often difficult and costly to find more nurses to hire to meet the ratios. The study however found that increased RN staffing enhances satisfaction with the patient workload but takes away the decision-making capability of nurses as they are expected to work extra hours to meet ratio requirements. The cost of hiring new nurses and temporary staff was indicated as a disabling factor in trying to meet the minimum nurse-to-patient threshold. In their study, Harding and Wright (2014) found that the desire to meet minimum nurse-to-patient ratios should never be divorced from the skill mix and competencies of nurses for optimal patient care outcomes to be attained.
In a review that set out to determine important issues in nurse staffing levels and skill mix, Flynn and McKeown (2009) found no apparent relationship “between nurse staffing levels and the organization of nursing work and various outcomes of interest” (p. 764). This particular study reinforces the argument that nursing skill mix and staffing level should go hand in hand if healthcare institutions want to enhance patient safety and improve nurse job satisfaction. However, a study conducted by van den Heede et al (2010) found that enhanced nurse staffing levels play a significant part in avoiding patient deaths and providing optimal patient care in hospital settings. Indeed, the findings of this particular study are clear that increasing nurse staffing levels in healthcare settings is more cost-effective than investing in other known interventions as it reduces hospital mortality and other adverse patient outcomes such as medication errors, increased rates of pneumonia, pressure ulcers, as well as urinary tract and postoperative infections.
Summary
The review identifies various pertinent issues that may adversely affect the adoption of minimum nurse-to-patient ratios in the United States. These issues include lack of more staffing (unavailability of RNs), cost concerns related to hiring more nurses, as well as the skill mix and competencies of nurses. Although most of the findings of the reviewed studies support the assertion that minimum nurse-to-patient ratios increase patient safety, reduce hospital mortality and enhance job satisfaction for nurses, the federal government and other relevant stakeholders need to do more to ensure that the issues of cost, skill mix, and unavailability of qualified nurses are addressed to spur the adoption of minimum nurse staffing ratios by reluctant states.
References
Aiken, L.H., Sloane, D.M., Cimmiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A…Smith, H.L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(4), 904-921.
Buerhaus, P.I., Donelan, K., DesRoches, C., & Hess, R. (2009). Registered nurses’ perceptions of nurse staffing ratios and new hospital payment regulations. Nursing Economic$, 27(6), 372-376.
Chapman, S.A., Spetz, J., Seago, J.A., Kaiser, J., Dower, C., & Herreira, C. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54(5), 321-355.
Flynn, M., & McKeown, M. (2009). Nurse staffing levels revisited: A consideration of key issues in nurse staffing levels and skill mix research. Journal of Nursing Management, 7(6), 759-766.
Harding, T., & Wright, M. (2014). Unequal staffing: A snapshot of nurse staffing in critical care units in New South Wales. Contemporary Nurse: A Journal of the Australian Nursing Profession, 47(1/2), 7-15.
Shekelle, P.G. (2013). Nurse patient ratios as a patient safety strategy: A systematic review. Annals of Internal Medicine, 45(4), 904-921.
van den Heede, K., Simoens, S., Diya, L., Lessaffre, E., Viegels, A., & Sermoens, W. (2010). Increasing nurse staffing levels in Belgian cardiac surgery centers: A cost-effective patient safety intervention? Journal of Advanced Nursing, 66(6), 1291-1296.
Grading Rubric
- Problem Identification Paper
- Nursing 145
- Fall 2015