In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
Teamwork: working well together in moments of crisis
Action taking: responding swiftly after identifying a complication
Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
Recognition of complications
Communication
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
The Massachusetts Nurses Association (MNA) is trying a
second time to establish patient limits in state legislation. This comes six
months after losing a ballot question in the November 2018 state election.
As reported by the Boston Business Journal, the current legislation being reviewed now would hire an independent researcher to study issues affecting nurses, such as staffing, violence, injuries, and quality of life. The data collected by the researcher will then be used by state legislators to determine healthcare staffing needs and acute care patient limits.
The original measure from this past election was defeated
largely because of lobbying from the Massachusetts Health & Hospital
Association (MHA), who spent $25 million to defeat the ballot. This current
bill would be revisiting the same legislation, which raises points for state
consideration regarding nurse staffing measures.
MNA has been working to get nurse-to-patient ratios at all Massachusetts
hospitals for several years, including a ballot measure in 2014 that was removed,
after Governor Deval Patrick passed a law patient limit law. Markman said this
study is necessary to convince voters, after the 2018 election.
“You are so overburdened. The situation has made it impossible to give the care you need to. We need more of you. We need much better staffing ratios. It’s really that simple.” –Congresswoman Jan Schakowsky (D-Illinois), author of Nursing Staffing Standards for Patient Safety and Quality Care Act (HR 1602), in a speech on Capitol Hill at the Nurses Take DC Rally
It had rained in Washington, D.C., for 15 straight days, but on May 12, 2016, the weather held off. Nurses from all over the country gathered under cloudy skies and congregated around a simple speaker stand with flags to either side stating, “Safe Nursing Ratios Save Lives.”
The ground was boggy, causing many nurses to sink into the mud, but none could turn their eyes away from the Capitol building that hung over the scene, a reminder of the power of the people. On this misty, humid, and rain-free day, nurses made their demands for safer staffing ratios known with the smell of wet grass in their noses and a cheer in their throats for the thoughts so passionately and aptly expressed by the many speakers.
The speakers roused the crowd with inspired words, and nurses held up signs in support of the legislation. They shared heartfelt stories of nurses and patients who have suffered poor ratios on the front lines. What happened on this slate gray day in front of the great building of government? Promises of safe ratios, belief in the power of legislation, and a comradery that transcended specialty, geography, and years of service rang out from Congresswomen and nurses alike.
Why Ratios?
Of all of the problems nursing has—bullying, burnout, and nurses leaving the profession—why are all of these people focusing on ratios? It is because ratios affect patient safety the most, and nurses are always focused on patient safety first.
Janie Harvey Garner, RN, founder and executive director of Show Me Your Stethoscope, was asked why she chose this issue for her group. “Because I have been that nurse with the third patient in the ICU,” she says. “I’ve been the nurse with the nine patients on med/surg. It’s not safe for anybody, and quite honestly, though I am extremely concerned about hurting a patient, I’m also very concerned about hurting a nurse because second victim syndrome is a super health issue, for me anyway. I don’t think it is with hospital organizations, but it sure is with me. Kim Hyatt died. Let’s not make it in vain.” (Hyatt committed suicide after making a medication error, which may or may not have been related to staffing issues.)
Rebecca Love, BA, MSN, RN, ANP, regional director for the North East region of Show Me Your Stethoscope and founder of HireNurses.com, went even further when she stated, “I think what we’re seeing in the hospital is verging on the level of we are choosing which patients are going to live and which patients are going to die every day when we come in and deal with the ratios that we are dealing with.”
In fact, Kelsey Rowell, RN, thinks that staffing ratios may be leading to some of the other problems that face nurses. “I think we’re spread so thin that it’s really causing nurses to experience compassion fatigue and feel tired. I think ratios are something that’s going to be ultimately good in a long haul.”
Ratios are the most important issue in nursing because it is about the patients. There is no way to get around that fact, and that is why this legislation is so important. Nurses need to stand up and be heard. People can and will die when nurses are spread too thin, and that not only hurts patients, but it severely impacts the psychology of the nurse.
The general public doesn’t even know this is an issue because they don’t know what nurses do. “Nurses need to speak about the value of their work,” says Sandy Summers, RN, MSN, MPH, founder and executive director of The Truth About Nursing, and coauthor of Saving Lives: Why the Media’s Portrayal of Nursing Puts Us All at Risk. “Moving their heads up high and saying, ‘I can’t possibly take care of four ICU patients, someone is going to die. I can barely take care of two.’ So working on safe staffing issues is ultimately joining our mission of working to educate the public about the value of nursing, the work that nurses do to save lives.”
The Legislation
The hubbub at the Capitol was due to the legislation that is now in the House of Representatives called HR 1602. There is also a Senate bill for nurse to patient ratios, but it is still in its very beginning stages. Like the California laws, this bill calls for mandatory ratios across the country. Here is what the bill proposes hospitals will have to offer nurses who work for them:
“[A] hospital’s staffing plan shall provide that, at all times during each shift within a unit of the hospital, a direct care registered nurse may be assigned to not more than the following number of patients in that unit:
One patient in trauma emergency units.
One patient in operating room units, provided that a minimum of 1 additional person serves as a scrub assistant in such unit.
Two patients in critical care units, including neonatal intensive care units, emergency critical care and intensive care units, labor and delivery units, coronary care units, acute respiratory care units, postanesthesia units, and burn units.
Three patients in emergency room units, pediatrics units, stepdown units, telemetry units, antepartum units, and combined labor, deliver, and postpartum units.
Four patients in medical-surgical units, intermediate care nursery units, acute care psychiatric units, and other specialty care units.
Five patients in rehabilitation units and skilled nursing units.
Six patients in postpartum (3 couplets) units and well-baby nursery units.”
Nurses posing with Congresswoman Jan Schakowsky
This bill was proposed by Congresswoman Jan Schakowsky (D-Illinois), a woman of great charisma and passion for nurses and ratios alike. She is moved by health care and the plight of nurses everywhere. “If we really want to improve patient care, we have to improve the nurse staffing ratio,” says Congresswoman Schakowsky. “There’s just no question about it. It is nurses that are on the frontlines. If they have too many patients, then nurses just can’t do the job that we need done.”
In the House, different representatives can agree to co-sponsor a bill, or lend their support to its cause. Two of those representatives are Congresswoman Donna F. Edwards (D-Maryland) and Congresswoman Joyce Beatty (D-Ohio), and both are passionate about the cause.
After a rousing speech to the nurses assembled, Congresswoman Beatty spoke with similar eloquence as to why she supports the bill: “It makes a difference in the lives of not only nurses but in the lives of patients. It’s good for patients. It’s good for health care. I want to say thank you for being out here because getting a bill passed and moving it along the way is standing up for what you believe in. I can go back to the house floor and I can say I believe in nurses.”
Congresswoman Edwards was similarly supportive of the bill and of nurses. “We want to make sure that our patients and our nurses are operating in the kind of environment that allows them to provide quality health care,” she explains. “That quality is jeopardized when nurses have so many patients to care for when they have some other responsibilities that don’t involve direct patient care.”
Nurses and Health Care
It’s great to talk about getting more nursing at the bedside, but nurses cost money. With the rising cost of health care, it may not be feasible to expect that the system could support better nurse ratios. The Affordable Care Act aims to get more people health insurance, but how does this impact nurses? More patients mean more work, higher ratios, and more stress. What is the solution?
Nurse talking to Congresswoman Donna F. Edwards
Congresswoman Edwards doesn’t see this as a problem: “It’s really clear that even under the Affordable Care Act, we’ve always known that we’re going to be in an environment where we need more nurses, more qualified care in medical settings, and that’s going to be really important with so many more people coming in to the system requiring care that staffing ratios are [an] important component of that kind of quality care.”
Obviously, this will need to be addressed if more patients are coming into the system. If there are no ratios in place, this could lead to very unsafe staffing in most facilities. That makes it even more important to pass this legislation . . . and to find ways to get more nurses to the bedside.
Congresswomen Schakowsky also wants more nurses: “We need to make sure that health care providers are also increased to make sure that we can actually deliver the care to these millions more people.”
“We’re trying to marry the two of the insurance and having good medical services,” says Congresswoman Beatty. “I don’t see them on separate ends. You can’t be for health care and be against good nursing. You can’t be for good nursing and be against health care.”
Despite the positive talk, the increase in patients will trickle down to nurses. This legislation needs to pass so that the facilities can’t just continue to add to the nurse workload because there are more patients than they know what to do with.
Ways to Improve Ratios
Ratios are obviously a problem, but legislation cannot possibly be the only solution. For starters, there are some flaws in the bill proposed, but laws can take a very long time to come into effect. Patients are dying now. Nurses are suffering now. There has to be something else nurses can do to impact this issue.
Rowell has a few ideas. “I think it’s going to start with awareness,” she says. “Maybe it’s going to be starting with people standing out and voicing everything going on and the severity of it. If we continue to let the business of the profession run what we do, we will focus on profit over patients’ safety, and that is a big deal.”
There are other factors that stand in the way, as well. Love points out that “I think that there are powerful interests at play that oppose this kind of change. Largely insurance and health care and hospital administrators because nursing costs money and the only way that we’re going to be able to fight that is when we state we will have mandated safe staffing levels.”
It is certainly true that insurance isn’t going to support staffing ratios. The more they keep costs down, the better. Unfortunately, this often comes at the expense of patients and nurses. With the Affordable Care Act, insurance companies will look to cut costs even more, and that is a dangerous precedent for the movement.
It is also true that facilities don’t tend to listen to nurses. They are seen as complainers, but even then, nurses can find a way to maneuver themselves into a better situation. “We have to encourage patients and their families, and caregivers to start questioning a lot more,” says Andrew Lopez, RN, president and CEO of Nursefriendly.com. “We have to feed them the information they need. Social media is an excellent vehicle. We can do that. Social media gives us a platform where we can go on to Facebook, we can go on to Twitter, and go on to communities where we will be welcomed as nurses, as ambassadors of health.”
Deficiencies to the Bills
One of the problems with the bill is that it doesn’t provide for an acuity scale. Although it is mentioned, a scale is not specifically written out. This can leave the door open for facilities to exploit it by giving nurses the required number of patients but swamping them with patients requiring a great deal of care.
“We want the hospitals to be working with the nurses to figure out exactly what number needs to be there,” says Congresswoman Schakowsky. “Obviously, when there’s greater acuity, we need to have even more nurses that are available. It’s clearly a big factor. We haven’t put a number in the bill but we want that taken into clear account.” However, leaving the negotiation to the hospitals may not be the best idea.
Congresswoman Beatty agreed and showed a remarkable knowledge of what nurses experience every day. “I think that’s one of the things we’re going to work through. Certainly when you know if a patient is sicker than another patient, they require more care. If you’re in intensive care or if you get an infection, the requirements are that it takes more work.”
Another glaring oversight of the bill is the lack of ratios for those in long term care and rehabilitation. In these specialties, registered nurses can have up to 40 patients with minimal support staff under them.
Summers stated that this was one problem with the bill that needed to be addressed. “A nurse told me in her rehab center, there are two nurses for every 17 ventilated patients. That is so reckless. But taking care of ventilated patients is hard. Their tubes always get blocked up. They get secretions and coughing. Eight and a half patients each? That’s reckless. She thought that wasn’t as bad as they have on the floor which is 40 patients each or 50, I think.”
Clearly, this is a problem, and it needs to be addressed in the bill. It is an oversight that has caused many to withdraw their support. For this reason and others, national groups like the American Nurses Association are not as supportive. “The ANA is not supportive of the current legislation, but that does not necessarily mean that they’re not supportive of us,” explains Garner. “I think they’re in general supportive of a grass root effort, but they certainly do not back the current legislation that we’re supporting.”
The Future
Although there are some flaws with the bill, the future may rely on its passing. This is why nurses support it—it is the best thing out there for the problems they face. What is the future of nursing and this bill?
Caroline Thomas from EmpowerRN states, “I think you know the future of nursing is very bright obviously. Statistically, we have a huge gap in the amount of nurses that we have and the amount of nurses that we’re going to need in the future. Having a degree in nursing, it opens up a lot of doors other than just the traditional. I definitely recommend it; I think it’s a great time to get in to it.” Despite the flaws, nursing still remains a profession that is worthy of pursuit.
Love has a completely different take on the future of nursing and of ratios: “I believe what’s going on, is that we are becoming so overburdened with the amount of patients that we are caring for that it is driving down the quality of care. It’s forcing nurses out of the profession and eventually we are going to end up with nobody by the bedside to care for patients. I think the future of nursing and the future of health care are at risk.”
Where is Show Me Your Stethoscope going from here? Garner is optimistic. “We’re going to continue to do nurse advocacy. We’ll also continue to do patient advocacy. Mostly, I see us doing what nurses want us to do because we’re a nurse’s organization. I don’t want to unionize the world. All we want to do is do what nurses want to do.”
In the end, nurses are fighting for their patients and themselves when everyone else doesn’t understand the struggle or even knows it exists. Advocacy for nurses is needed. Education of the public is also necessary. Legislation is only one road. Starting a dialogue and standing up for nurses is the way to lasting change. This is the future of the staffing ratio debate, and with this rally, nurses are off to a great start.
How many patients can a nurse reasonably care for at one time? This is perhaps the biggest issue facing the nursing profession right now. In fact, there are two bills in Congress right now that seek to decide just this, not only to protect patients but also the nurses who care for them.
California is the only state in the United States that regulates the number of patients a nurse can have under his or her care. The safe staffing law was passed there in 1999 (more than 15 years ago!) and it went into effect in 2004. The law breaks down the maximum number of patients for a nurse by acuity and type of care.
But in 49 other states and in the District of Columbia, there is no mandated limit to the number of patients a nurse can safely or reasonably be expected to care for.
What does this mean? This means on busy days in an emergency department, nurses may be caring for 4-6 acutely ill patients, some of whom need to be transferred to the intensive care unit, to a telemetry unit, or to the OR. This means a psychiatric nurse could be expected to care for more than 10 patients at a time, or that on a low-staffed unit at night, a med-surg nurse may be caring for up to eight or more patients.
A nurse’s name on a patient’s chart confers ultimate responsibility for that patient’s safety and well-being. The expectation is that the nurse will prevent a patient from harm and will keep a patient safe. It is the nurse who will discover a medication error before it gets to the patient (whether it be an error on the part of a resident or the doctor or the pharmacist); she or he will keep a patient from falling should they try to get up out of bed unassisted, and he or she will medicate, assess, chart, document, comfort, and care. But what happens when that nurse is stretched so thin there is no possible way for her to ensure a patient’s safety? The patient is at risk, and so is the nurse’s license. How can she be everywhere at once when she is caring for five or even six patients at a time?
Unfortunately, this is an issue that is unlikely to be resolved in the near future, despite the two bills currently before Congress. Over the next decade, the number of aging baby-boomers continues to increase while the number of new nurses entering the workforce decreases (not to mention those nurses leaving the profession altogether as a result of burnout and fatigue). Administrators still incorrectly fear the cost ramifications of nursing mandates. Specifically, the bill would require hospitals to write a staffing plan, and “allows a nurse to object to, or refuse to participate in, any assignment if it would violate minimum ratios or if the nurse is not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing the nurse’s license.” Importantly, the bill also carries an anti-retaliation clause. The bills are a start, but are not a panacea by any means. And, they have yet to pass.
Earlier this week, a report released by Johns Hopkins purports that medical errors are the third leading cause of death in the United States each year. The high number of deaths relating to errors point not to bad doctors or to mistakes, but more to systemic problems, a lack of standardization, a lack of reporting and data collection about mistakes, and issues with medical staff turnover, burnout, and fatigue. Many people are quick to point out the myriad studies correlating positive patient outcomes and higher levels of nurse staffing, as well as the decrease patient lengths-of-stay.
It’s not that data don’t exist, as hundreds of studies demonstrate the positive relationship between patient safety and nurse staffing. Moreover, studies also show that increasing nursing staff does not contribute to higher hospital costs. A longitudinal study by the Agency for Healthcare Research and Quality concluded that it actually decreased costs over time, including a decreased patient length-of-stay. Additionally, increased nurse staffing has been shown to decrease patient mortality, increase patient satisfaction, and decrease nursing turnover and job dissatisfaction.
Safe staffing is an issue that is not likely to fade, and many nurses are eagerly tracking the legislation before Congress. A rally to demonstrate support of safe staffing is planned in Washington, DC, for May 12th. More information can be found here.
