RN Staffing Ratios: The necessity of regulated nurse staffing ratios to ensure patient safety and improved outcomes for hospitalized patients

Description

As a result of the natural experiment of the nurse to patient ratio law in California, we now have evidence that nurse to patient ratios are a significant factor in patient safety and outcomes. This CE course examines the efficacy of mandated nurse to patient ratios in improving patient outcomes, so enhancing registered nurses ability to provide optimal care and work environments. It will further examine the many benefits of mandated numerical ratios in recruiting and retaining a motivated registered nurse workforce.

Objectives

Upon completion of this home study, RNs will be able to:

Enumerate the benefits of nurse to patient ratios, which along with an acuity system, enhance patient outcomes and registered nurse recruitment and retention.
Compare and contrast evidence-based patient and nurse outcomes between California and other states without current ratio legislation including Pennsylvania and New Jersey
Name two factors identified by the Institute of Medicine that increase the risk of nursing errors
Identify and describe 2 advocacy actions RNs can take to reduce the risk of patient harm and poor outcomes

Statement of the Problem

There is a patient safety crisis in the United States. Every day it is estimated that 700 people die from preventable errors in their medical treatment or complications from those errors. Conservative estimates place the annual death toll from preventable errors, errors that should never occur in a safe hospital setting, at approximately 250,000 per year (Markary & Daniel, 2016). Other estimates place this figure at an alarming 400,000 deaths per year (Classen, et al., 2011). When counted, preventable death caused by medical error is the third leading cause of death in the United States (Markary & Daniel, 2016).

Registered nurses (RNs) across the nation have been sounding the alarm over this crisis for over two decades. Nurses have witnessed preventable death and disability daily at their patients’ bedsides in hospitals big and small from coast to coast. Despite these warnings, hospitalized patients remain at risk and the consequences are alarming. The long-held perception of nurses that there are simply not enough nurses present in hospitals to provide the care needed has been validated by dozens of studies. Nurses know that one of the most effective ways to protect patients is through safe and effective staffing. Yet, in 49 states there is no limit to the number of patients a nurse can be made to care for at one time and the safety crisis continues. Throughout years of advocacy, the nation’s largest healthcare workforce has witnessed the implementation of failed policy initiatives, ill-conceived schemes to replace nurses with less skilled and unlicensed staff, and attempts to redesign healthcare with a focus on experimental technology that has introduced the risk for additional types of preventable medical error.

As the death toll continues, nurses now urge policymakers to take much needed action to save lives and prevent needless harm by implementing evidence-based, mandatory, minimum nurse-to-patient ratios that are improved upon as individual patient needs warrant. Research from the last few decades has overwhelmingly shown that safe staffing levels and ratios help improve patient outcomes in mortality, adverse events, complications, failure to rescue, quality of care, costs, and length of stay. Safe staffing levels also help decrease nurse burnout and job dissatisfaction (Bae, Mark, & Fried, 2010). While California is the only state that has such a mandate, other states must follow to ensure continued quality patient care and nurse retention. The results of California’s experience demonstrate that mandatory nurse-to-patient ratios increase patient safety and quality of care. Implementing this necessary protection is sound, life-saving healthcare policy.

Background and Significance

Registered nurses are a critical component in guaranteeing patient safety and the highest quality health care. Yet, beginning with a 1996 study entitled, “Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?” a series of Institute of Medicine (IOM) reports initiated massive shifts in attention and effort to study hospital staffing and patient outcomes. During the following decade, there was an undercurrent of tension between hospital administrators and staff nurses regarding how many nurses are enough, what their roles should be, and how to recruit and retain them. Hospitals, with an eye on the bottom line, spent most of the 1990’s reducing their RN workforce through layoffs and attrition.

Reengineering and restructuring undertaken by hospital management has been designed to emulate industrial models of productivity improvement rather than address nurses’ concerns about fundamental flaws in the redesign of clinical care services and fragmentation of the hospital workforce. Many nurses began speaking out and reporting that staffing in hospitals was deteriorating and unsafe.

By 2001 two thirds of U.S. nurses were reporting that their hospitals did not have enough nurses to provide high-quality care, and 45% said the quality of care had deteriorated significantly in the previous year. A Commonwealth Fund survey of doctors published that year found that doctors ranked nurse staffing levels of hospitals as one of their most serious concerns in being able to provide top-quality health care. A subsequent survey of physicians revealed 64% rated hospital nursing staff levels as fair to poor. Patients and their families were also expressing dissatisfaction with their care and an increasing number began bringing private duty nurses with them to the hospital.

Hospital-based errors leading to the deaths of up to 98,000 patients per year were viewed as scandalous by many. The Institute of Medicine, which produced the report, studied all conceivable variables related to deterioration of patient care conditions except RN staffing ratios according to the Institute for Health and Socio-economic Policy. Hospitals began implementing a variety of nursing care delivery systems, involving so-called “transformational care” and “clinical work redesign” schemes to reconfigure staffing patterns. This clinical restructuring reduced the proportion of RNs to other nursing and/or unlicensed “assistive” personnel and led to increased concerns among direct care RNs about the threats to their ability to provide safe, therapeutic and effective patient care.

As hospitals signaled to nursing schools that fewer nurses were needed, school budgets were slashed and training programs for RNs were cut. This was occurring when the increasing complexity and acuity of hospital caseloads called for even more skilled nursing care provided by registered nurses. Hospitals hired consulting firms, paying them hundreds of millions of dollars to implement work/role redesign models with an emphasis on shifting registered nurses away from hands-on care to serve as “team leaders” of the lower paid, lower skilled licensed and unlicensed assistive personnel.

Guided by market-driven goals of cost-cutting and profit-making rather than assurance of quality care, health firms began to implement restructuring programs in the corporate, clinical and technology arena. Although based on a manufacturing model that devalues the intellectual work of nursing by breaking up the nursing process into a series of “tasks”, these schemes are often referred to as “patient-centered” or “patient-focused” care.

Patient care staffing standards sharply deteriorated in hospitals across the country as hospitals cut vital services. Administrators failed to staff available beds in order to maximize their profitability. Patients and nurses experience the effect every day with unsafe staffing levels. Many nurses fled the profession due to unsafe staffing, mandatory forced overtime and double shifts.. They feared the conditions would cause them to harm patients and they feared losing their license when required to delegate complex care to lower skilled workers. Today, it is still legal for RNs in 49 states to be assigned 10 to 16 patients, or more, at a time!

Work Place Hazards and Risk of Patient and Nurse Harm

Although there are five categories of potential workplace hazards found in hospitals, the U.S. Department of Labor’s Occupational Safety and Health website lists “stress, workplace violence, shift work, inadequate staffing levels, heavy workload, financial constraints and increased productivity demands/speed up, increased intensity of work, exposure to occupational violence and increased patient acuity in the ‘Psychological Hazard’ category. This category is defined as: “Factors and situations encountered or associated with one’s job or work environment that create or potentiate stress, emotional strain, and/or other interpersonal problems.” Implications for the quality and efficacy of the healthcare an organization provides have been a particular focus on investigations of stress and burnout, both generally and specifically are related to psychological aggression, hostile work environments, horizontal violence and bullying.

Stress and burnout in nurses negatively affects patients’ perception of the quality of their care and also contributes to a higher likelihood of medical errors. Stress-related attrition exacerbates already inadequate nurse-to-patient ratios and can generate considerable labor costs for healthcare organizations. A survey of turnover in acute care facilities found that replacement costs for nurse positions were equal to or greater than 2 times their annual salaries. All of these factors are cited in the literature as being associated with or potentiated by too few staff and/or an insufficient number of appropriately licensed, clinically competent RN staff present and available to provide a high standard of safe, therapeutic, and effective patient care. Research has shown these risks can be mitigated by increasing the proportion of RNs available to care for patients.

As consumers, we expect specific standards for clean air and water; limits on classroom sizes; and staffing ratios for airlines, day care centers, and nursing home staff. Hospital patients and the registered nurses who care for them should also be entitled to minimum safety standards and public protection. High acuity patients, a high number of patients per nurse, changes in skill mix, models of care delivery, technology, organizational restructuring, fatigue, frequent interruptions and workflow redesign continues to occur. Each of these changes in the RN practice environment potentiates the risk of patient harm, nurse burnout, and low nurse and patient satisfaction according to the Institute of Medicine (2004).

Nursing Staff in Hospitals: Is it Adequate?

Institute of Medicine Studies

In September of 1994, CNA presented written and oral testimony for consideration by the Institute’s Committee on Adequacy of Nursing Staffing. The Association presented several key points:

The adequacy of nursing staffing is an important factor in protecting patient safety and maintaining positive patient outcomes.
Inadequate levels of nurse staffing and/or inappropriate skill mix of nurse providers have been long-standing and complex problems with a cyclically recurring pattern over a period of many years.
Research has shown that higher levels of staffing and higher ratios of RNs to total nursing personnel are significantly related to better outcomes of care.
RNs caring for patients with too few or the wrong mix of personnel deal with “near misses” often on a daily basis.
“Near misses” are not just occasional events or expected human mistakes. Instead they are largely preventable or correctable events that result from too few or inappropriately assigned personnel to assess and handle patient care needs appropriately.
The concept of “near misses” encompasses a wide range of potentially dangerous situations which nurses, if present, detect, prevent, correct, or attenuate.

CNA’s testimony, drawn from survey reports and letters submitted by thousands of RNs and members of the public documented the real risks that Californian RNs and their patients face every day due to unsafe hospital staffing as a result of hospital restructuring. The survey reports and letters were submitted by CNA to the California Department of Health Services detailing specific incidents of unsafe staffing and extensive narratives on “near misses” and adverse outcomes. A summary of the survey results identified the following:

Staffing has worsened.
Current staffing does not allow time for unexpected events—which occur regularly.
Overall patient acuity has increased.
Changes in skill mix and/or layoffs of hospital personnel have had a negative effect on patient care.
Nurses have witnessed inappropriate transfers of patients who were too sick to be sent home or to a less acute care area of the hospital.

The IOM Committee, at the time, refused to recognize the importance of RN staffing levels and skill mix on quality of patient care in hospitals regardless of existing empirical evidence. Dr. Patricia Prescott published the evidence in 1993 after conducting a comprehensive review. Overall she found substantial evidence linking RN staffing levels and mix to important mortality, length of stay, cost, and morbidity outcomes. Increased RN core clinical staffing was shown to reduce mortality, length of stay, cost, complication rates, and improve both RN and patient satisfaction.

However, the IOM reports were not the first set of clear statements of concern regarding hospital safety and quality. Nor were these reports the first efforts at calling attention to the need for data, public reporting, and the consideration of health care quality in light of payment for care. More than 140 years earlier, Florence Nightingale, the founder of modern nursing, raised these same issues. In spite of the passage of well over a century between Nightingale and the release of the IOM reports, seemingly little attention was paid in the interim to creating safer health care environments.

Three comparisons of Nightingale’s concerns and recommendations with those expressed in the IOM reports illustrate similar problem identification as well as a shared view regarding the building blocks essential to creating solutions. First, in her publication, Notes on Hospitals, Nightingale identified the paradox of the problem at hand: “In practice a hospital may be found only to benefit a majority and to inflict suffering on the remainder”. Well over a century later, To Err Is Human reports, “… a person should not have to worry about being harmed by the health system itself”. Nightingale goes on to say, “Even admitting to the full extent the great value of hospital improvements of recent years, a vast deal of suffering, and some at least of the mortality, in these establishments is avoidable”. Similarly, To Err Is Human notes, “A substantial body of evidence points to medical errors as a leading cause of death and injury”.

Finally, in a search for solutions and with an eye toward measurement, developing evidence, public reporting, and linking payment with quantifiable performance, Nightingale theorized, “It is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed ticket—and the inquiry … arises in the mind, what can be the cause?” Related to this, To Err Is Human notes, “Sufficient attention must be devoted to analyzing and understanding the causes of errors in order to make improvements”.

There Ought to Be A Law!

The California Nurses Association sponsored AB394 to ensure safe staffing for patients in California. AB394 was introduced by California Assemblyperson Sheila Kuehl and it was passed by the legislature, after extensive and aggressive lobbying and highly visible mobilization campaigns by RNs as advocates for the adoption of this important patient safety legislation. It was signed into law by Governor Davis on October 10, 1999, adding section 1276.4 to the Health and Safety Code (HSC). This law is the nation’s first law mandating nurse staffing ratios for acute-care hospitals.

In adopting the new bill, the Legislature declared that the accessibility and availability of nurses is essential "to ensure the adequate protection of patients in acute care settings." The Legislature clearly believed that the quality of patient care was related to the number of licensed nurses at the bedside, and wished to ensure a minimum, adequate number. The California Department of Health Services (DHS) was charged with determination of and implementation of the staffing ratios.

Previous attempts were made to obtain mandated ratios in California. The first attempt was in 1993 when AB1445 was introduced into the Assembly, but the bill died in committee. In 1996, CNA sponsored an HMO reform ballot initiative, Proposition 216, which included a requirement for the DHS to set ratios in health care settings. In 1997, AB695 passed the legislature; but it was vetoed by then Governor Wilson after an aggressive anti-reform lobbying campaign financed by the hospital and insurance industry.

Key Components of the California Nurse-to-Patient Ratio Law

Safe Staffing Legislation-Legislative Findings

Health care services are becoming complex and it is increasingly difficult for patients to access integrated services.
Quality of patient care is jeopardized because of staffing changes implemented in response to managed care.
To ensure the adequate protection of patients in acute care settings, it is essential that qualified registered nurses and other licensed nurses be accessible and available to meet the needs of patients.
The basic principles of staffing in the acute care setting should be based on the patients’ care needs, the severity of condition, services needed, and the complexity surrounding those services.”

Limits on the Utilization of Unlicensed Assistive Personnel (UAPs)

The acute care facility shall not assign UAPs to perform nursing functions in lieu of RNs
The acute care facility may not allow UAPs under the direct supervision of a registered nurse, to perform functions that require a substantial amount of scientific knowledge and technical skills.

Adoption of Nurse-to-Patient Staffing Ratios

The Department of Health Services (DHS) shall adopt regulations that establish minimum, specific, and numerical licensed nurse to patient ratios by licensed nurse classification, hospital unit, for all acute care facilities.

In adopting the nurse-to-patient ratio regulations, the Licensing and Certification Division of the Department of Health Services was required to take into consideration the regulations dealing with RN scope of practice and existing staffing and patient classification system regulations.

AB 394 Staffing Standards Mandates

Uniform Minimum Nurse-to-Patient Standards Plus Flexing Up Based on Patient Acuity
Once the minimum number of RNs has been allocated, additional staff shall be assigned in accordance with a documented Patient Classification System (PCS) for determining nursing care requirements.
New PCS-Required Patient Care Indicators
Severity of Illness
Need for specialized equipment and technology
Complexity of clinical judgment needed to design, implement, and evaluate the patient care plan
Ability for self care
Licensure for personnel required for care

Hospital Unit Definition

Hospital unit means a critical care unit, burn unit, labor and delivery room, post-anesthesia recovery service area, emergency department, operating room, pediatric unit, step-down/intermediate care unit, specialty care unit, telemetry unit, general medical care unit, sub-acute care unit, and transitional in-patient care unit. The regulation addressing the emergency department shall distinguish between regularly-scheduled core staff licensed nurses and additional licensed nurses required to care for critical care patients in the emergency department.

In California, the Department of Health Services, has defined hospital units and appropriate patient population for the purposes of licensing and certification of healthcare facilities and for monitoring compliance with existing public health and safety regulations. Because the literature describes the most common factor underlying preventable complications/failure-to-rescue as "triage error" or, admission to a unit other than one that provides the optimal level of care required by the patient, it's instructive to include a review of unit/patient population definitions upon which the California nurse-to-patient ratio law and staffing standards are predicated.

Title 22 Section 70217, Mandated Minimum Numerical Nurse-to-Patient Ratios by Unit Type Section 70217 (a). Nursing Service Staff

The licensed nurse-to-patient ratio in a critical care unit* shall be 1:2 or fewer at all times. “Critical care unit” means a nursing unit of a general acute care hospital which provides one of the following services: an intensive care service, a burn center, a coronary care service, and acute respiratory service, or an intensive care newborn nursery service.

Department of Health Services/Final Statement of Reasons (DHS/FSOR): 70217 (a) (1) “Critical care unit is defined at Health and Safety Code (HSC) 1276.4(c)(*Critical care unit in this section means a unit that is established to safeguard and protect patients whose severity of medical conditions requires continuous monitoring and complex intervention by licensed nurses.) “Intensive care newborn nursery service” was added to the list of critical care units to clarify that it is included as a critical care unit. It is DHS’ intent that the phrases “intensive care units” and “critical care units” may be used interchangeably. Intensive care units are mandated at 22 California Code of Regulations (CCR) 70495 to have a minimum nurse-to-patient ratio, of 1:2 or fewer, at all times. The 1:2 ratio standard has become the minimum ratio for critical care units, with many patients in those units requiring staffing at 1:1 and even 2:1.

The surgical service operating room shall have at least one registered nurse assigned to the duties of the circulating nurse and a minimum of one additional person serving as scrub assistant for each patient-occupied operating room. The scrub assistant may be a licensed nurse, and operating room technician, or other person who has demonstrated current competence to the hospital as a scrub assistant, but shall not be a physician or other licensed health professional who is assisting in the performance of surgery.

DHS/FSOR: 70217 (a) (2): This provision makes explicit the requirement for a registered nurse (RN) to function as the circulating assistant in the surgical service operating room, 22 CCR, section 70223, Surgical Service. The most critical period of care for surgical patients occurs in the operating room. The instability inherent in the patients’ condition while undergoing surgery necessitates the registered nurse’s level of skill for ongoing assessment and evaluation, while assisting the surgical team. The ongoing assessment includes minute-by-minute vigilance and availability for immediate response to emergent patient changes on the part of the circulating registered nurse.

The licensed nurse-to-patient ratio in a labor and delivery suite of the perinatal service shall be 1:2 or fewer active labor patients at all times. When a licensed nurse is caring for antepartum patients who are not in active labor, the licensed nurse-to-patient ratio shall be 1:4 or fewer at all times.

DHS/FSOR: 70217 (a)(3) This is based on the patients’ need for critical care during the end of labor and through the delivery process. The 1:2 ratios conform to the ratios for the other critical care units in the hospital.

The licensed nurse-to-patient ratio in a postpartum area of the perinatal service shall be 1:4 mother-baby couplets or fewer at all times. In the event of multiple births, the total number of mothers plus infants assigned to a single licensed nurse shall never exceed eight. For post partum areas in which the licensed nurse’s assignment consists of mothers only, the licensed nurse-to-patient ratio shall be 1:6 or fewer at all times.

DHS/FSOR: 70217(a) (4). In Guidelines for Perinatal Care, both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, (representing the specialty’s physicians, recommend a nurse-to-patient ratio of 1:6 for postpartum patients without complications and 1:4 for normal mother-newborn couplet care. The Association of Women’s Health, Obstertric, and Neonatal Nurses, representing the specialty’s nurses agrees that those are the appropriate ratios.

The licensed nurse-to-patient ratio in a combined Labor/Delivery/Postpartum area of the perinatal service shall be 1:3 or fewer at all times the licensed nurse is caring for a patient combination of one woman in active labor and a postpartum mother and infant. The licensed nurse-to-patient ratio for nurses caring for women in active labor only, antepartum patients who are not in active labor only, post-partum women only, or mother baby couplets only shall be the same ratios as stated in subsection (3) and (4) above for those categories of patients.

DHS/FSOR: 70217 (A)(5). In a combined LABOR/Delivery/Postpartum area of the perinatal service, the minimum nurse-to-patient ratio is to be 1:2 or fewer at all times.

The licensed nurse to patient ratio in a pediatric unit shall be 1:4 or fewer at all times.

DHS/FSOR: 70217 (a) The word “unit” was added because current regulations at 22 CCR 70543(a) to differentiate between the pediatric service and the pediatric unit. Other hospitals which admit pediatric patients but do not have pediatric units would admit the pediatric patients to a mixed unit, and that ratio, in concert with the (PCS) would dictate the appropriate staffing level.

The licensed nurse-to-patient ratio in the post anesthesia recovery unit of the anesthesia service shall be 1:2 or fewer at all times, regardless of the type of anesthesia the patient received.

DHS/FSOR: 70217(a) DHS concurs with the California Society of Anesthesiologists which wrote, “The CSA supports the proposed DHS nurse-to-patient ratio of 1:2 or fewer for patients in the post anesthesia recovery unit. The most critical phase for a patient recovering from anesthesia, whether it is general, regional, or intravenous, is the immediate period following surgery and anesthesia, before they are transitioned to an inpatient setting or discharged to a lower level of care.

In a hospital providing basic emergency medical services or comprehensive emergency medical services, the licensed nurse-to-patient ratio in an emergency department shall be 1:4 or fewer at all times that patients are receiving treatment. There shall be no fewer than two licensed nurses present.

DHS/FSOR: 70217(a) (8) At least one of the licensed nurses shall be a registered nurse assigned to triage patients when they arrive in the emergency department. When there are no patients needing triage the registered nurse may assist by performing other nursing tasks. The registered nurse assigned to triage patients shall not be counted in the licensed nurse to patient ratio. When licensed nursing staff are attending critical care patients in the emergency department, the licensed nurse to patient ratio shall be 1:2 or fewer at all times.

The licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times.

A "step down unit" is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. "Artificial life support" is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. "Technical support" is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology.“Artificial life support” and “ technical support” are defined in regulation in order to differentiate the types of equipment and nursing care that would commonly be required by patients in step down units, and, by extension, the degree of illness or impairment experienced by patients in this unit type.

The licensed nurse nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.

"Telemetry unit" is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals.

The licensed nurse-to-patient ratio in medical/surgical care units shall be 1:5 or fewer at all times.

A medical/surgical unit is a unit with beds classified as medical/surgical in which patients, who require less care than that which is available in intensive care units, step-down units, or specialty care units receive 24 hour inpatient general medical services, post-surgical services, or both general medical and post-surgical services. These units may include mixed patient populations of diverse diagnoses and diverse age groups who require care appropriate to a medical/surgical unit.

The licensed nurse-to-patient ratio in a specialty care unit shall be 1:4 or fewer at all times.

A specialty care unit is defined as a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population. Services provided in these units are more specialized to meet the needs of patients with the specific condition or disease process than that which is required on medical/surgical units, and is not otherwise covered by subdivision (a).

The licensed nurse-to-patient ratio in a psychiatric unit shall be 1:6 or fewer at all times. For purposes of psychiatric units only, “licensed nurses” also includes licensed psychiatric technicians in addition to licensed vocational nurses and registered nurses.

DHS/FSOR: 70217(a) (13) The severity of psychiatric disorders, varies in acuity.
PTs, like LVNs, practice under the direction of a physician, psychologist, registered nurse, or other professional personnel, and are not independent practitioners.

Identifying a unit by a name or term other than those used in this subsection does not affect the requirement to staff at the ratios identified for the level or type of care described in this subsection.

DHS/FSOR: 70217 (a) (14) This provision was added to allow providers maximum flexibility in the naming of their units. Some hospitals give units names that are perceived to be less troubling for patients and their families than the regulated unit names. For example, Intensive Care Newborn Nurseries may be named the “Special Care Nursery,” and an Oncology Unit may be called the “Camellia Care Unit,’ etc. this provision ensures that, while providers may use unit names that they believe will be best received by the population they serve, the use of those names does not affect nor avoid the requirement to comply with the staffing regulations that are based on the type of care provided, and not merely the name of the unit.

As a direct care registered nurse in a general acute care hospital, having comprehensive knowledge about the DHS findings and reasons for adopting these specific minimum numerical nurse to patient ratios is imperative to your role as a patient advocate. These ratios constitute the minimum allowable at all times, and the law further requires that staffing must be flexed up/augmented based on the individual acuity of your patient.

Passing the Baton: The History of Safe RN Staffing Ratios in California

The 1996 congressionally mandated Institute of Medicine study concluded that evidence-based standards were insufficient to guide hospitals, nurses, and policymakers in prescribing hospital nurse staffing. Pronovost (1995) and his associates helped fill this void by creating an evidence base for establishing nurse staffing standards. Their study examined the relationship between nurse-to-patient ratios in the intensive care units (ICUs) of Maryland hospitals and the risk for complications after abdominal aortic surgery. They found that patients in hospitals where ICU nurses care for three or more patients have significantly increased risk for medical complications compared with patients in hospitals where ICU nurses care for one to two patients. Of interest, California adopted an ICU nurse-to-patient maximum staffing ratio of 1 nurse to 2 patients in 1975. It was signed into law by then governor Jerry Brown.

Pronovost et al. had provided evidence to validate that standard. On the other hand, the researchers noted that employing fewer nurses to care for patients would cost hospitals more. Inadequate nurse staffing levels lead to increased resource use, particularly in the form of longer lengths of stay, thus negating expected labor savings. Having an ICU nurse-to-patient ratio of less than 1:2 during the day increased mean ICU days by 49%.

The findings of a 20-hospital study conducted by Aiken, et al. of inpatient AIDS care are similar to those of Pronovost and colleagues. She found substantial variation across hospitals in risk-adjusted 30-days-from-admission mortality among patients with AIDS, as well as substantial differences in nurse-to-patient ratios. After accounting for other important factors, Aiken and her colleagues estimated that staffing up with an additional nurse per patient-day cut the odds of dying by more than half.

The researchers also found that the hospitals that had the most favorable nurse-to-patient ratios had significantly shorter overall length of stay as well as fewer ICU days. Thus, the overall cost of care was no greater in hospitals with a more favorable nurse-to-patient ratio. These findings add to the evidence presented by health economist Dr. Uwe Reinhardt in his compelling essay, “Spending More through ‘Cost Control’: Our Obsessive Quest to Gut the Hospital”. Reinhardt showed that flawed accounting practices in health care often result in managerial and policy decisions that adversely affect patients without reducing costs. More than a decade of research suggests that the organizational climate in which care takes place is as important as staffing in determining patient outcomes.

The effects of excellent nurse staffing can be undermined in organizations that restrict nurses’ autonomy to act within their scope of expertise, that provide inadequate administrative support, or that fail to give nurses authority commensurate with their high level of responsibility for patient well-being. Recent restructuring and re-engineering of hospitals have adversely affected nurses’ practice environments and contributed to the current perception of an acute shortage of hospital nurses.

As early as 1992, the Department of Health Services (DHS) considered proposing regulations requiring staffing ratios for registered nurses in acute care hospitals. However, at that time, DHS determined not to impose minimum ratios and instead opted for regulations requiring that hospitals implement a Patient Classification System ("PCS"). The PCS was intended to ensure that the number of nursing staff was aligned to the health care needs of the patients, while still allowing the provider flexibility for the efficient use of staff. The PCS regulations provide a framework to establish nursing staff allocations based on nursing care requirements for each shift and each unit.

The PCS system requires the establishment of a method to predict nursing care requirements of individual patients. This method must address the amount of nursing care needed, by patient category and pattern of care delivery, on an annual basis, or more frequently, if warranted by the changes in patient populations, skill mix of the staff, or patient care delivery model.

The PCS system also requires:

a method by which the amount of nursing care needed for each category of patient is validated for each unit and for each shift;
a method to discern trends and patterns of nursing care delivery by each unit, each shift, and each level of licensed and unlicensed staff;
a mechanism by which the accuracy of the nursing care validation method described above can be tested;
a method to determine staff resource allocations based on nursing care requirements for each shift and each unit; and
a method by which the hospital validates the reliability of the patient classification system for each unit and for each shift.

Following the adoption of the PCS, DHS spent more than four years working with nursing and hospital organizations, including the California Nurses Association, to develop the final PCS regulations, which became effective on January 1, 1997. Although it does not appear that any formal studies were conducted to determine the effectiveness of the PCS, it was the perception of many direct care RNs that the PCS was not meeting the patients' needs for staffing. CNA claimed this perception was supported by a 1998 survey conducted by the DHS itself. According to the Senate Health and Human Services Committee, as reported by the Senate Rules Committee:

"In 1998, the DHS surveyed over 160 acute care hospitals during the Consolidated Accreditation and Licensing Survey and found that most of the hospitals surveyed were not in compliance with Title 22 patient classification. 61% of the facilities were out of compliance with Title 22 with 87% deficient in the specific sections that require the facility to establish a PCS and to staff based on patient needs. It became clear that the majority of facilities were not complying with Title 22."

Consequently, the CNA concluded that the PCS was not meeting its intended purpose, and sponsored AB 394 to require the establishment of minimum numerical licensed nurse-to-patient ratios. AB 394 is the first nurse-to-patient acute care staffing ratio law in the United States. However, the history of nurse staffing ratios predates AB 394 by many years.

The Evolution of the California Nursing Practice Act

During the 1973-74 legislative session, the CNA's "Proposed New Legal Definition of Nursing" became the framework for AB 3124, which amended Business and Professions Code section 2725 (the "Nursing Practice Act") to amplify and define the role of the registered nurses in the provision of healthcare. Business and Professions Code section 2725 explicitly recognizes the existence of overlapping functions between physicians and registered nurses and permits additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses. (Bus. & Prof. Code § 2725.)

The statute defines the practice of nursing to mean those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including "[d]irect and indirect patient care services." Subsequent to adoption of the Nursing Practice Act, DHS adopted a regulation establishing "Standards of Competent Performance" for registered nurses. (See 16 CCR § 1443.5.)

Standards of Competent Performance

The Standards of Competent Performance provide that a registered nurse shall be considered competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as demonstrated in a number of circumstances. The nursing process is the process used to organize and deliver appropriate nursing care; it is based on the model of the scientific method of inquiry.

Under the statute and regulations, registered nurses ("RNs") are required to:

formulate a nursing diagnosis through observation of the client's physical condition and behavior and interpretation of information obtained from the client and others;
formulate a care plan, in collaboration with the client, which ensures that direct and indirect care services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures;
evaluate the effectiveness of the care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and health team members; and
act as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided. (See 16 C.C.R. § 1443.5.)

Patient-Focused Conditions of Advocacy

Another provision in the ratio law is that an RN must provide, among other things, ongoing patient assessments as defined in the Nursing Practice Act, and the planning, supervision, implementation, and evaluation of nursing care to each patient in accordance with the elements of the Nursing Process.

California law is also unique, in that it codifies and defines the nursing process in the Standards of Competent Performance and it explicitly recognizes the RNs professional duty and right to act as a Patient Advocate.

The law sets forth the four specific conditions of advocacy: the RN must act as the patient’s advocate, as circumstances require, by

Initiating action to improve health care;
to change decisions or activities which are against the interests of their patients;
to change decisions or activities which are against the wishes of their patients;
to ensure the patient has the opportunity and/or the ability to make informed decisions about health care before it is provided.

The nursing profession grew out of the public demand for educated, formal caregivers devoted to the public good. Throughout our history, nurses have espoused the idea that that care giving during health and illness must be organized around individuals, families, and communities rather than disease processes alone. Nurses recognize the effect of culture in shaping the definition of health and illness and interpreting human responses to physiological and biological changes across the life span. It is a nurse’s duty to recognize and remove barriers and threats to their ability to serve as patient advocates.

As nurses we have done an assessment and we have recognized that lack of sufficient staffing to meet the needs of our patients poses significant risks to their general health, safety and welfare. In congruence with our professional values, all people will have a uniform national standard of care that addresses the nursing shortage and improves the health and safety of our patients and protects them from harm.

The professional ethics and integrity of RN caring and social justice are congruent with our belief that all individuals are of equal worth and are thus entitled to be able to meet their basic human needs, experience equality of opportunity and be protected from unjustifiable inequalities. Support and advocacy for this legislation is the most ethically and morally defensible position for you to take. Americans trust that their nurses will act as advocates in their behalf.

Outcomes are better for nurses and patients in hospitals that meet a benchmark based on California nurse staffing mandates whether the hospitals are located in California. The higher the proportion of nurses in hospitals whose patient assignment is in compliance with the benchmark set on California- mandated ratios, the lower the nurse burnout and job dissatisfaction, the less likely nurses are to report the quality of their work environment as only fair or poor, the less likely nurses are to report that their workload causes them to miss changes in patients’ conditions, and the less likely nurses are to intend to leave their jobs.

Similarly, the higher the percentage compliance with a benchmark based on California ratios, regardless of the hospital state location, the less likely nurses are to report complaints from patients or families, verbal abuse of nurses by staff or patients, quality of care that is poor or only fair, and lack of confidence that their patients can manage after discharge.

Nurses must use the advocacy skills they’ve learned at the bedside to educate the public and influence the Congress to enact a transparent, enforceable safe staffing standard. Research has demonstrated that there’s a certain nursing workload level above which it’s inherently dangerous for patients. Staffing ratios are clearly associated with better outcomes for both nurses and patients.

As nursing is both a science and an art, nurse advocacy needs to be informed by science and a holistic approach to patient care. As there are many misconceptions and myths surrounding the ratios, usually promulgated by the health care industry, it is important that registered nurses are aware of these misconceptions This home study will now focus on the benefits to patients and nurses afforded by mandated minimum nurse to patient ratios and also dispel misinformation regarding the ratios in greater detail.

Mandating minimum RN-to-patient ratios saves lives and improves patient-care outcomes

Lawfully mandated minimum nurse staffing levels at hospitals in California have been proven to save lives and enhance patient care. The California Nurses Association (CNA), an affiliate of the nation’s largest organization of registered nurses, National Nurses United (NNU), championed the development, passage, and enforcement of the nation’s first mandatory unit-specific nurse-to-patient ratios for acute-care hospitals. CNA drafted and sponsored the legislation that became California’s nurse-to-patient ratios law and was heavily involved in California’s three-year rulemaking process to develop the final numerical ratios. After over a decade since California implemented its nurse-to-patient ratios law, NNU’s experience indisputably demonstrates that legislative and regulatory mandates on minimum nurse-to-patient staffing improves patient care and saves lives.

A seminal study from 2010 on the impact of California’s ratios compared California hospitals’ post-implementation of the state’s minimum nurse-to-patient ratios law to hospitals in New Jersey and Pennsylvania and found, unsurprisingly, that if New Jersey and Pennsylvania matched California’s ratios in medical surgical units, then New Jersey would have 13.9 percent fewer patient deaths and Pennsylvania 10.6 percent fewer deaths. Compared to states without ratios, the study found that California RNs reported having more time to spend with patients and that hospitals are more likely to have enough RNs on staff to provide quality patient care (Aiken L. H., 2010). In fact, the lead investigator of this study reported to the San Francisco Chronicle that “The differences between California and the other states are striking,” said Linda Aiken. “Nurses in California take care of two fewer patients on average than nurses in Pennsylvania and New Jersey in general surgery. These differences lead to the prevention of literally thousands of deaths.” (Ornstein, 2010)

The study also found that California nurses were significantly less likely than their New Jersey and Pennsylvania counterparts to report that workload causes them to miss changes in patient conditions (Aiken L. H., 2010). A more recent study from 2016 that compared hospitals in Pennsylvania, New Jersey, Florida, and California confirmed the earlier findings that California’s improved nurse-to-patient staffing ratios improved patient care (McHugh M. D., et al., 2016). This study focused on hospitals that saw ten or more cardiac arrest events during the time under study and found that for every additional patient assigned to a nurse, the likelihood of a patient surviving cardiac arrest decreased by five percent per patient.

The success of California’s nurse-to-patient ratios law confirms what other more general studies on nurse staffing have long shown. For example, a 2013 meta-analysis of twenty-eight prior studies found a consistent relationship between higher RN staffing and lower hospital related mortality (Shekelle, 2013).

Similarly, a 2007 meta-study found that an increase in staffing equivalent to one full-time RN was associated with a 9 percent decrease in deaths in ICU patients, a 16 percent decrease in deaths in surgical patients, and a 6 percent decrease in death in medical patients (Kane, Shamilyan, Mueller, Duval, & Wilt, 2007). A 2006 study showed that if all hospitals increased RN staffing to match the best-staffed hospitals in the country, 5,000 in-hospital patient deaths and 60,000 adverse patient outcomes could be avoided (Needleman J., Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). Yet another study found that increased RN staffing is associated with shorter patient stays, lower rates of urinary tract infections, lower rates of gastrointestinal bleeding, and lower rates of failure to rescue (Needleman J., Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). As California’s nurse-to-patient ratios law has demonstrated, minimum safe patient staffing levels unquestionably results in safe patient care and improved patient outcomes.

Inadequate RN staffing is dangerous for patients, increasing rates of infection, error, illness, and mortality

When nurses are assigned too many patients, they are at higher risk of preventable medical errors, avoidable complications, falls and injuries, pressure sores, increased length of stay, and readmissions. Empirical studies have confirmed time after time that understaffing of nurses and high nurse workloads is dangerous for our patients.

One study found that higher patient workloads of nurses has an independent and direct effect on quality of care, contributing to reduced patient safety, medical errors, patient falls, and unfinished nursing tasks (Kane, Shamilyan, Mueller, Duval, & Wilt, 2007).

Other studies have found comparable results. One found that understaffing in intensive care units increases risk of medical complications. Another study found that for each additional surgical patient in an RN’s workload above the baseline nurse-to-patient ratio of 1:4, the likelihood of patient death within 30 days increases by 7 percent. And yet another study comparing California, New Jersey, and Pennsylvania found that each additional patient assigned to a nurse was associated with 7 percent higher risk of readmission for heart failure, 6 percent higher risk of readmission for pneumonia, and 9 percent higher risk of readmission for myocardial infarction (McHugh & Ma, 2013).

California’s ratio law sets a floor and is not a “one-size-fits-all” standard by accounting for additional staffing to meet individual patients’ needs

Contrary to the deceptive refrain by industry, laws establishing minimum nurse-to-patient staffing ratios are just that—floors on nurse-staffing levels that ensure safe patient care.

The ratio law as enacted is akin to other workplace and public health statutes and regulations that set baseline rules to protect the health and safety of both caregivers and the patients they serve. The ratio law demands merely what patients deserve—quality care when they seek healthcare at hospitals.

It is routine for the industry to respond to patient, nurse, and legislator calls for minimum safe nurse staffing laws with threats of staffing cuts, reduced hiring standards, or cuts to programs. As described above, however, these industry threats are merely a thinly veiled attempt by hospitals to protect their profits despite the harm to patients that results from inadequate RN staffing.

Nurse-to-patient ratios increase nurse autonomy and stress the professional judgment of the direct-care registered nurse

Nothing in the California minimum nurse-to-patient ratios law involves reduction in healthcare employer hiring standards or cuts in programs. Rather, the California minimum nurse-to-patient ratios law demands, inter alia, that the individual care needs of each patient and the skill mix of healthcare staff be assessed by the assigned RN to determine whether circumstances require additional staffing above the minimum staffing ratios.

In California’s experience implementing its mandatory minimum nurse-to-patient ratios law, these requirements were critical in the success of any minimum nurse-staffing law. In its lobbying against the California ratios, the industry repeatedly argued that hospitals would be “forced to compensate for the ratios by cutting other staff” (California Department of Health Care Services, 2003). Industry advancement of this argument that minimum staffing ratios would result in budget-driven staffing cuts was so prolific that the state’s Department of Health Care Services directly addressed this issue in its Final Statement of Reasons in support of the ratio regulations, explaining that hospitals could not respond to the ratios by reducing overall staffing. To ensure that reduction in overall staffing did not occur, the California law required that each hospital establish an acuity system “to determine the amount of nursing care needed by each unit, on each shift, and for each level of licensed and unlicensed staff.” (California Department of Health Care Services, 2003)

Not just patient safety, the California RN staffing ratio law has improved nurses’ health and safety

A 2015 study, which examined occupational injury and illness rates before and after the California RN staffing ratio law was passed, showed what RNs already know— safer nurses means safer patients (Leigh, Markis, Losif, & Romano, 2015).

Researchers examined the rates of occupational injury and illness to registered nurses in California before and after the RN staffing ratio law was passed, looking at a range of years from 2000 to 2009. They compared this data to the occupational injury and illness rates for registered nurses in the other 49 states and D.C. that have not adopted minimum numerical staffing ratio laws. They found that the California RN staffing ratio law was associated with a 31.6% reduction in occupational injuries and illnesses among RNs working in hospitals in California.

California’s ratios law demonstrates that compliance with minimum nurse-to-patient staffing laws is undoubtedly feasible, resulting in improved nursing work environments and hospital savings

California’s success with implementation of its mandated minimum nurse-to-patient staffing ratios law belies industry arguments that there are not enough RNs to comply with mandated nurse-to-patient ratios. The comparative study of California after the implementation of the state’s ratios law discussed above also found that California hospitals are in compliance with the ratios a super-majority of the time, just two years after the laws effective date. In fact, the study found that nurses in New Jersey and Pennsylvania had more patients than permitted by California’s ratios as much as 81 percent of the time, depending on the unit, whereas California nurses are able to meet the ratios 81–94 percent of the time, depending on unit (Aiken L. H., 2010).

The comparative study of California to New Jersey and Pennsylvania also found that California’s ratios have positively affected nurses’ overall work environment and their corresponding ability to deliver patient care. The study went on to find that “[n]urse workloads in California hospitals in 2006, 2 years after the implementation of mandated nurse staffing ratios, were significantly lower than in New Jersey and Pennsylvania hospitals” (Aiken L. H., 2010). It also concluded that in medical and surgical units “where nurse recruitment and retention has long been difficult nationally, nurses in California on average care for over two fewer patients than nurses in New Jersey and 1.7 fewer patients than nurses in Pennsylvania” (Aiken L. H., 2010). Overall, compared to their nurse counterparts in New Jersey and Pennsylvania, nurses in California care for an average of one fewer patients and reported more favorable outcomes with respect to every work environment measure analyzed, including reasonable workload, adequate support staff, and enough RNs to provide quality patient care (Aiken L. H., 2010)

Other studies support these findings that RN staffing ratios mean safer RNs, who have more time to provide quality and safe care for their patients. These findings include:

Nurses from units with low staffing and poor organizational climates were twice as likely as nurses on well-staffed and better organized units to report risk factors for needlestick injuries and near misses (Clarke, Sloane, & Aiken, 2002).
An increased patient load per nurse was associated with significantly higher likelihood for neck, shoulder, and back musculoskeletal disorders (Lipscomb, Trinkoff, Brady, & Geiger-Brown, 2004).
Risk for workplace violence injuries was twice as high for lower-staffed hospitals as compared to higher-staffed hospitals (Lee, Gerberich, Waller, Anderson, & McGovern).

In other words, the provision of safe and therapeutic patient care depends on RNs having safe patient workloads. Safe working conditions for nurses improves the quality of patient care.

A different survey of California nurses after the implementation of California’s ratios law also found that California nurses reported significant improvements in working conditions and job satisfaction (Spetz, 2008). In short, the study demonstrates that California’s ratios have resulted in California nurses caring for fewer patients at a time, positively impacting both the working environment and patient care.

It is also important to note that the specter of outsized costs to industry is unfounded. Improved nurse job satisfaction and patient outcomes will reduce spending on temporary RNs and overtime costs and lower RN turnover (Bland-Jones, 2008). Ratios both attract and retain registered nurses. A recent Texas Center for Nursing Workforce Study on hospital nurse staffing vacancy and turnover rates for registered nurses showed RN turnover rates in California to be dramatically lower than states without ratios, such as Florida and Texas (Texas Center for Nursing Workforce Studies, 2016). According to Pricewaterhouse Coopers in its report, What Works: Healing the Healthcare Staffing Shortage, the cost of replacing one registered nurse is between $40,000–$85,000; given this it is evident that ratio implementation saves individual hospitals from both the expense and clinical disruption of a rapid turnover of its nursing staff. The report states that, “Every percentage point increase in nurse turnover costs an average hospital about $300,000 annually” (PricewaterhouseCoopers’ Health Research Institute, 2007).

Improved nurse working environment, likewise, translates into savings from improved patient outcomes (Encinose & Hellinger, 2008) and shorter patient lengths of stay (Needleman J. , Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). After the implementation of California’s ratio law, nurses in California experienced burnout at significantly lower rates than those in New Jersey and Pennsylvania, and reported less job dissatisfaction (Aiken L. H., 2010). Both burnout and job dissatisfaction are precursors to turnover. A 2009 study estimated that adding 133,000 RNs to the U.S. hospital workforce—the number of RNs needed to increase nursing staff to the 75th percentile— would produce medical savings of $6.1 billion, not including the value of increased productivity when nurses help patients recover more quickly (Dall, 2009).

Combining medical savings with increased productivity, the addition of 133,000 RNs would result in an economic value of $57,700 for each of the additional RNs (Dall, 2009).

Mandatory minimum nurse-to-patient staffing levels are feasible, resulting in better nurse workloads and hospital savings from lower turnover and improved patient outcomes.

Conclusion

Registered nurse staffing levels that facilitate safe, competent, therapeutic, and effective care is vital to the safety of patients in U.S. hospitals. Allowing hospitals to set staffing levels that are primarily budget driven, while not setting up a system of accountability, has created a threat to patient safety. Without necessary safeguards, hospitals may engage in nurse staffing cuts to save money, thereby adversely affecting patient outcomes (Aiken et al. 2014). The only way to ensure that all hospitals have safe staffing levels that are consistently adhered to is through mandated nurse-to-patient ratios. Currently, California is the only state in the United States that has mandated RN-to-patient ratios. As examined in detail above, research reveals that these ratios are associated with lower mortality, lower nurse burnout, and better nurse retention. Despite calls of alarm from the hospital industry, the ratios have not had an adverse impact on operations or quality of care. In fact, the evidence overwhelmingly demonstrates that in the face of an epidemic of preventable medical errors, RN staffing ratios must be implemented without delay to prevent disability and preserve thousands of lives.

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