How many patients can one nurse safely handle? Is there an optimal nurse-to-patient ratio? Does patient care suffer when there aren’t enough nurses per patient?
These aren’t just academic questions. They go to the heart of one of the more contentious issues in the hospital industry these days: the flashpoint where staffing levels, patient care and profitability collide.
If you’ve been following the news of a pending strike by 12,000 nurses at Twin Cities hospitals, you’ll know that staffing levels are one of the key issues at stake. The hospitals want the ability to adjust staffing in response to patient volume, a move the Minnesota Nurses Association contends is unsafe for patients.
As revenue continues to tighten and hospitals look for ways to become leaner and more efficient, the public can expect to hear a lot more in upcoming months about the nurse-to-patient ratio.
Not surprisingly, it’s an emotional issue. It’s also one that happens to be rather well studied, and most of the studies suggest patients fare better when the hospital is staffed with an adequate number of skilled nurses.
One of the most widely cited studies is this one, which appeared in the Journal of the American Medical Association in 2002 and examines the nurse-to-patient ratio, patient mortality and job dissatisfaction and burnout among nurses. The authors conducted a survey and collected data at 168 hospitals in Pennsylvania and, after analyzing the results, concluded there were “detectable differences in risk-adjusted mortality and failure-to-rescue rates across hospitals with different registered nurse staffing ratios.”
Another key finding from this study: Nurses who worked at hospitals with a high patient-to-nurse ratio were much more likely to report job dissatisfaction and burnout.
These findings have important implications for patient safety and the hospital nurse shortage, the study’s authors wrote:
Our results document sizable and significant effects of registered nurse staffing on preventable deaths. The association of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contribute importantly to surveillance, early detection, and timely interventions that save lives. The benefits of improved registered nurse staffing also extend to the larger numbers of hospitalized patients who are not at high risk for mortality but nevertheless are vulnerable to a wide range of unfavorable outcomes. Improving nurse staffing levels may reduce alarming turnover rates in hospitals by reducing burnout and job dissatisfaction, major precursors of job resignation. When taken together, the impacts of staffing on patient and nurse outcomes suggest that by investing in registered nurse staffing, hospitals may avert both preventable mortality and low nurse retention in hospital practice.
When the U.S. Agency for Healthcare Research and Quality undertook a review of the existing research, several more conclusions came to light. First, many hospitalized patients are very sick and require considerable care. The AHRQ cited research showing a 21 percent increase in the acuity level between 1991 and 1996 – but no net change in the number of registered nurses. In fact, many hospitals have sought to increase staff efficiencies by hiring nursing assistants to take over some of the more basic tasks of patient care, a move that tends to add to the supervisory workload of RNs.
The AHRQ’s report also attempts to quantify the cost of adverse events that might be associated with short-staffing the number of hospital nurses. The report notes, for instance, that pressure ulcers account for at least $8 billion in health care spending per year.
Yet another study suggests the cost of having more nurses on staff is balanced by shorter hospital stays for patients and fewer complications and adverse events.
Is there a right ratio for how many patients one nurse can safely care for? This isn’t easy to pin down, as this position paper, produced by the New England Public Policy Center and the Massachusetts Health Policy Forum, demonstrates. It can depend on the hospital unit – intensive care patients, for instance, are sicker and require more care than a same-day surgery unit. It might also depend on the particular mix of patients who are hospitalized on any given day, and on the overall resources of the hospital. There may also be a point of diminishing returns beyond which the benefits of ramping up the nursing staff are minimal.
Patients and the public aren’t accustomed to discussing these policy questions. For the most part, the dialogue about nurse-to-patient ratios has taken place between nursing organizations and hospitals. And maybe that’s appropriate, but the public has a stake here too. If we’re ever hospitalized, or have a family member in the hospital, we’re going to notice if there aren’t enough nurses to go around and it affects the care we receive. We’re also going to notice if we end up paying more for hospital care. It seems only right to give the public more opportunity to become informed and to get involved in this important discussion.
Update, June 4: Check out MinnPost for this thoughtful take on the connection between numbers of nurses, hospital costs and quality of care.