Nursing Notes

April 11, 2010

Not Enough Nurses, Not Enough Time: The Crux of Nurse-to-Patient Ratios

Here’s an article that looks at staff to patient ratios from a different perspective.  These nurses are in upper management and are not only concerned with staffing but with patient outcomes as it affects payment by the payor source.

At the hospital system where I work, the TCAB (Transforming Care at the Bedside) committees have initiated the PDA studies at various hospitals and on various units.  The information from these studies is very interesting and shows that nurses spend quite a bit of their time doing non-nursing things–faxing orders, waiting for the doctor to call back, talking to other departments about results, looking for lost items, gathering supplies.  So I was interested to see that our results were in line with the results in this article.

I encourage all nurses to take part in this movement to identify what exactly nurses are doing during the shift and to help quantify the time spent actually doing patient care.  After all, isn’t patient care really why we became nurses?


By Pat Muccigrosso, contributor

March 24, 2010 – How many patients per nurse is the right number to ensure patient safety? Or is it more than just a numbers game?

These questions have been a topic of debate for years; in recent years, they’ve become the object of legislation.  California led the way in 2004, when it enacted a law mandating nurse-to-patient staffing ratios.  To date, a total of 13 states have introduced legislation to address nurse staffing, and 25 states are considering additional laws.

Melinda Schoen, RN, MSN
Melinda Schoen, RN, MSN, VP of nursing at Masonicare Health Center, says that the ratio of nursing staff to patients affects patient safety.

But the question that started this rush to legislation remains:  Does adding more registered nurses help hospitals reduce adverse outcomes and “never events” like medication errors, falls and pressure ulcers?

“The ratio of staff to patient does affect patient safety.  The higher number of patients per nurse makes it more difficult because you are spreading yourself across a larger group of patients,” says Melinda Schoen, RN, MSN, vice president of nursing at Masonicare Health Center in Connecticut. “If you have fewer patients, you’re able to be spend more time per patient, be visible and involved throughout the shift, meeting their needs and preventing risky situations.”

Recent studies have also shown a correlation between nurse staffing and patient outcomes.  One retrospective study presented at the March 2010 American Academy of Orthopedic Surgeons meeting found that patients 65 and older with a hip fracture are more likely to die when admitted to hospitals with lower nurse staffing levels.  The researchers commented that nursing levels may affect mortality and other outcomes by influencing the chances of preventing complications, identifying complications earlier and mobilizing help quickly.

In another study published in the March issue of Medical Care, nurse staffing was shown to have a statistically significant, independent association with in-hospital mortality.

Lillee Gelinas, RN, BSN, MSN, FAAN, VP and CNO of VHA, Inc.
Lillee Gelinas, RN, BSN, MSN, FAAN, VP and CNO of VHA, Inc., says that nurse staffing levels and time at the bedside affect outcomes.

Lillee Gelinas, RN, BSN, MSN, FAAN, vice president and chief nursing officer, VHA, Inc., agrees that staffing affects outcomes, especially in these tough economic times.  “Hospitals have been downgrading or reducing staffing levels.”  Gelinas says hospitals may think they are helping their bottom line in the short-term, but in the long-term “they may be hurting themselves.  There are not enough nurses at the bedside to detect clinical deterioration which leads to this term ‘failure to rescue’ — a direct reflection of nursing care in a hospital.”

Failure to rescue became prominent in 2004, when the National Quality Forum (NQF) published its Nursing Sensitive Care Performance Measures and it was first on the list.  But Gelinas says that failure to rescue may just be symptomatic of a far greater issue.  “When we’re thinking about ratios and safety, I like to say we don’t have a shortage of nurses; we have a shortage of nursing care.”

Gelinas cites national research done by Kaiser Permanente that shows that when nurses spend 60 to 70 percent of their time in direct patient care, safety and outcomes are dramatically improved.  “In American hospitals, the average nurse only spends maybe 30 percent,” says Gelinas.

Margaret Cousart, RN, BSN, CRN-C, CCDS
Margaret Cousart, RN, BSN, CRN-C, CCDS, director of clinical improvement at VHA Georgia, discovered that nurses sometimes take on non-critical activities that take them away from the bedside.

A year-long effort by nurses at the Georgia VHA hospitals demonstrated that it’s not always a staffing shortage that keeps nurses from the bedside, and administrators weren’t the only ones who missed that.  “The perception of the nurses throughout the hospitals was that they actually were spending more time with patients,” said Margaret Cousart, RN, BSN, CRN-C, CCDS, director of clinical improvement at VHA Georgia.   “The reality was that they were only spending 30 to 40 percent of their time in direct patient care.”

Using proprietary software and retooled PDAs, nurses at 11 hospitals in VHA Georgia were asked to track how they were spending their time.  They found that they wasted a lot of time waiting for a lab result to come back or a drug to come up to the floor or for a phone call from a physician.  They also lost time at the bedside because they were dealing with lost and found items, handling security issues, coping with broken equipment or performing clerical duties like faxing, phoning and copying.

Although most of the nurses were aware of the non-patient care activities that used up their time, even they were surprised at the magnitude of the problem.

Once VHA Georgia discovered what kept nurses from the bedside, they took a closer look at the details, according to Cousart. “We did gap assessments across all our hospitals, and developed action plans to find ways to take away some of the things nurses had embraced as their job over the years but really weren’t. “

Getting nurses back to the bedside is the very place that registered nurse Nora Watts says nurses do the work that prevents “never events” and failure to rescue.  “I should be at the bedside looking at the patient.  Are they sweating?  Is there a change in their mental status?  Is there anything going on that would tell me that something is going wrong?”

Watts, who works in the ambulatory transfusion center at Newton Wellesley Hospital in Massachusetts worries that administrators might try to cut costs by hiring unlicensed people or simply buying more technology – but that would be another mistake.  “Technology is great but you have to correlate what you find to what you see is actually happening with that patient.  That is what we do, what nurses do at the bedside.”

While short staffing keeps nurses away from the bedside in some cases, Gelinas says that the shortage of care is the real, underlying problem. “For me, that is the bottom-line message.”

“I think there’s truth to both,” counters Schoen.  “As a profession, we do get pulled away from the bedside.”   But she agrees with Gelinas that adding staff, in and of itself, doesn’t necessarily solve the problem: quality and results are the keys. Solving the problem means achieving “statistics showing that you are able to reduce falls or reduce medication errors with a certain staffing level — putting black and white detail and information together.”

At the heart of the problem, says Gelinas is one simple fact.  “We don’t have cultures of safety in American hospitals.  We are so financially driven that the agendas and conversations in the C-suites are not around how we instill a culture of safety.”

One way to change the culture, says Gelinas is by “hitting hospitals in the financial area.  It’s already begun.  Last October, the Centers for Medicare and Medicaid Services (CMS) stopped paying hospitals for complications of care called ‘never events’ things that should never happen like falls, pressure ulcers.”

And that’s just the beginning.  Gelinas pointed out that on June 1, 2010, CMS will begin reporting failure to rescue rates.  “Hospitals that opt out of reporting their failure to rescue rates would have to accept a 2 percent reimbursement rate.”

As transparency becomes a larger part of the business of healthcare, hospitals that fail to ensure patient safety through safe staffing levels, more nursing time at the bedside and other measures may end up paying a far larger bill in the months and years ahead.

Here’s the link to the original article

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  1. “We don’t have cultures of safety in American hospitals. We are so financially driven that the agendas and conversations in the C-suites are not around how we instill a culture of safety.”

    I think that quote says it all. Thanks for posting another excellent article, Shirley!


    Comment by kitchrn — April 13, 2010 @ 4:53 am | Reply

  2. Part of the problem – at least as I have experienced it – is a general issue of staffing and the proper division of labor. Sometimes, unit secretaries can be troublesome, while at others, they can be God sends! And then, there are the unlicensed personnel, upon whom we rely to perform many of the non-licensed tasks that we frequently find ourselves doing.

    When folks are under appreciated – whether licensed or not – they will not perform. When they are appreciated, they will often go out of their way to assist.

    It’s all about teamwork, isn’t it?

    Great post! Thanks for sharing!

    Comment by Warm Southern Breeze — April 18, 2010 @ 3:16 am | Reply

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