Doing More with Less: Are We Compromising Patient Care?
Submitted by Anita Schilling
I came bustling into the Medical-Surgical unit at the hospital where I work as scheduled. It was the third 12-hour shift I was working, so I was really looking forward to getting the shift over with and enjoying the upcoming four days off. I was expecting to come onto the floor to find the usual nurses on the unit. I had grown accustomed to their way of working and had become very comfortable working with them, also I frequently used their expertise if I came across a hard case. I was getting shift report from the night shift nurse when I was approached by the nurse manager, disheveled and looking rather worried. She informed me that I would be working short because Lisa, one of the usual nurses I liked working with was pulled to ICU and telemetry unit. The nurse manager informed me that because of company cuts and back-ups, this was a permanent change. Working short is now the norm. Staffing and outcomes is a frequently reviewed area of research because it has great significance for practitioners and educators as well as managers and policymakers (Clarke and Donaldson, 2008). In ratio terms, the more patients a nurse looks after the greater the ratio becomes. For example, a nurse to patient ratio of 1:6 is a higher or increased ratio than a nurse to patient ratio of 1:3.
While it is suggested that nurses are the core healthcare professionals, patient care and outcomes are significantly affected by many members of the multidisciplinary team. Nevertheless, the contribution of all members of the healthcare team in patient care is essential, but the nurse has the greatest contact and involvement with the patient (Garretson, 2004).
Staffing levels can be affected by a wide range of factors which can be influenced by administrative decisions, quality of nursing care, care needs and safety, and clinical outcomes. The following are key variables described by Clark and Donaldson that affect staffing level:
- “Staffing levels are set by administrators and are affected by forces that include budgetary considerations and features of local nurse labor markets” (2008).
- “Variables in care needs of the patient include the acuity and complexity of the patient’s health status, as well as the patient’s co-morbid medical conditions, functional status, family needs and recourses and the capacity for self-care” (2008).
- “The quality of nursing care relates to the appropriate execution of assessments and interventions intended to optimize patient outcomes and prevent adverse effects” (2008).
Due to these variables in staffing, nurses are at a higher risk of legal consequences if they are required to take on increased patient cases. According to a study by Garretson, the number of malpractice payments made by nurses in the United States increased from 253 in 1998 to 513 in 2001 (2004).
According to research, there are no evidence-based minimum staffing ratios although operating ratios are set every day by clinicians and nurse managers. However, mandated ratios are being implemented across the country. For example, a state law in California mandates that “each hospital unit uses an institutionally selected, acuity based workload measurement system to determine required hours of care for each patient” (Clarke and Donaldson, 2008). The California Nurses Association states that this reduces mortality levels and allows nurses to spend more time with patients (Garretson, 2004).
Studies indicate that nursing morale is at an all time low with negative attitudes and apathy. There are many factors that can account for this; however the number of nurses along with the increase in patient load are the most significant factors. Research shows that low morale in the nursing community can lead to additional stress, reduced performance, and decreased thoroughness in detail. A study published in by Alderman et al. reported “16% of the nurses interviewed claimed nursing was a dead-end job, 35% would not recommend nursing as a profession to others, and 28% regretted entering the profession” (1996, p. 23).
Much of the research on staffing has been done in the acute care setting. Settings such as pediatrics, childbearing families, and mental health patients have gone relatively unnoticed in research. Funding is needed to generate research in those underdeveloped settings (Clarke & Donaldson, 2008).
This short synopsis indicates that action must be taken to ameliorate nurse to patient ratios, bringing the total number of patients assigned to each nurse down to manageable levels. Cost-reduction may be the central issue for managers; however the consequences of reducing the amount of nursing staff to control costs are disconcerting to say the least. As more of the United States moves toward considering mandated nurse to patient ratios like California, healthcare administrators and political leaders will become more aware of the issue. Duchene states that “by decreasing a patient’s average length of stay by one hour per day, an estimated annual savings could reach 2 billion dollars in California alone. If this is accurate, the money that could be saved nationally would be staggering” (2002, p. 34). Reducing cost while maintaining patient safety is possible and more states should follow California in taking the initiative to implement similar mandates.
- Alderman, C. et al. (1996). Nursing Shortages: A virtual reality? Nursing Standard, 10, 19, pp. 22-5.
- Clarke, S. & Donaldson, N. (2008). Nurse Staffing and Patient Care Quality and Safety. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockwell, MD. Agency for Healthcare Research and Quality.
- Duchene, P. (2002). Staff Ratios: Just about numbers? Nursing Management, 33, 7, 10, pp. 33-7.
- Garretson, S. (2004). Nurse to Patient Ratios in American Healthcare. Nursing Standard,19, 14-16, pp. 33-7.