Abstract Two major forms of staffing guidelines will be discussed, nurse-to-patient ratio and staffing by acuity. This paper will discuss the history of each staffing form. It will point out the benefits and negative features of both practices, describe how hospitals deal with staffing and discuss the states that have laws requiring certain guidelines be followed. Nurse Staffing: Does One Size Fit All? What is the one conversation that usually gets heated when talking to nurses? Bring up the subject of staffing levels on their unit.
As a nurse assistant, staff nurse, charge nurse or nursing administrator, inadequate staffing creates tension and stress. When staffing is inadequate patient safety, infection rates, patient satisfaction and staff satisfaction are only a few of the areas affected. Many hospital administrators and lawmakers want to make patient care a numbers game. The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to create a staffing plan that defines staffing effectiveness as the skill mix, competence, and effectiveness related to the services needed.
(Morgan, 2004) When it comes to staffing, one size does not always fit all. Patients are individuals with individual needs and one patient with a certain diagnosis can take much less attention and time from the nurse than a patient of the same age with the same diagnosis. For good nurses the main goals during their shift is giving exception patient care and providing a safe environment. “The notion of high-quality care in hospitals is essential to public safety isn’t new. In 1751 Benjamin Franklin founded America’s first hospital-Pennsylvania Hospital-and commented that patients ultimately suffer and die without sound nursing care.
” (Clarke, 2003) Nursing leaders are under tremendous pressure to lower costs while improving quality. (Carter, 2004) It is often found that hospitals during low census times or times of budget cuts will try to let ancillary staff go and assign their duties to the nurse caring for the patient. Nurses can replace several other positions in a healthcare setting but no other position can replace the nurse. Nursing is not only a highly trained individual but someone who is called to be compassionate, caring and dedicated individual.
There are many reasons why staffing by acuity or nurse-to-patient ratios should not be mandated by lawmakers. Direct care nurses should be involved in staffing decision. Outcomes are better when nurses have control of their workload. (Anonymous, 2005) Adequate staffing must be priority for anyone involved in healthcare and there are pros and cons to both staffing by acuity and nurse-to-patient ratios. With our aging population and the increased age of the baby boomer generation nurses are going to increase in demand. Healthcare is changing so quickly and this also affects the shortage.
The average acuity of patients has increased over the last decade while the nursing shortage continues. Nurse-to-patient ratios are supposed to draw people into the filed but there is a shortage of educators at present time as well. Many colleges have long waiting list for nursing programs, yet many nurses only stay in the field for a short time after graduating. Many universities turn away good candidates to nursing programs due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.
(Allen, 2008) We as a nation must come to a conclusion to deal with the nursing shortage. Too many lawmakers are paying attention to the staffing formats suggested above and not doing anything to fix the nursing shortage. Whether by acuity or ratios, for each nurse to take fewer patients we will definitely need more nurses. Staffing by acuity is a format used to decide how many nursing hours are needed for certain diagnosis or types of patients. Typically areas within a healthcare facility where patients are less ill such as rehabilitation and medical-surgical units, nurses can care for as many as seven patients at a time.
Their acuity score is much lower than a patient in the intensive care unit or a step-down unit. Healthcare systems that utilize staffing by acuity are looking at the safe number of certain levels of patients that one nurse can care for. The down side to staffing by acuity is that many feel administration will influence numbers to maintain a high number of patients per nurse. If all patients on a unit were a level eight then most acuity systems would call for three patients to one nurse but if all patients on a unit were all level ones then a nurse could be caring for as many as eight to ten patients.
Acuity does not take every patient encounter into consideration. For instance a dementia patient may have a low acuity based on the nursing care since they usually do not have indwelling lines or invasive procedures. Although the same patient may require a high amount help with activities of daily living, decision making and education. (Walsh, 2003) Thus staffing by acuity can be a subjective form of nurse staffing. When done accurately, acuity based staffing can be very beneficial for the nursing staff.
Illinois is one of many states that have implemented laws requiring hospitals to base staffing on acuity systems and then report compliance on a quarterly basis. Illinois Hospital Association supports acuity based staffing over nurse-to-patient ratios. (Anonymous. 2008) SB867 is a law in Illinois that requires hospitals to base staffing on a model that has been developed by a nursing care committee made up of at least 50% direct care nurses. (Anonymous. 2008) This assures the bedside nurse a significant voice in the staffing process.
It allows nurses to base their staffing on the work they perform. The model should include levels of care and examples that fit you patient population. At times, nurses will under staff themselves by simply not giving their patients credit for their true acuity level. This law and practice demonstrates hospital’s commitment to their direct nurse staff. Acuity based staffing is believed to take all facts into the picture. Nurses should be trained to develop and use their acuity tool to best describe the patients they are caring for, thus supporting the need for additional staff.
Nurse-to-patient ratios are a concept that mandates a certain number of patients for each nurse to care for. Depending on the types of patients being cared for this number can differ. California has a law requiring nurse-to-patient ratios be following in hospitals. This law was signed in 1999 but was unable to be implemented for another four years. California state guidelines say that medical-surgical patients are one to five and in the intensive care units ratios are one to one. Illinois also has a law up for approval, HB0485 that would mandate ratios. “Establishing a minimum,
specific and numerical ratio implies that there is a scientific basis for determining the number of nurses to patients above which good outcomes patients can be guaranteed. ” ( Flowers, 2009) This law would put even more stringent regulations on hospitals. California has seen many issues related to the ratios law. Ratios can cause longer transfer times for patients, increased ER bypass and postponed elective surgeries. California has experienced 12 hospital closures and downsizing of services since ratios was implemented. Patients are not all alike, their needs are individually different.
Nursing units are different and ratios do not take into account the nurse’s level of experience or the physical layout of the facility. Many times hospitals will attempt to meet ratio laws by terminating such positions as nurse assistants and environmental services workers. So in reality nurses may only have four patients to care for but they are responsible for total care of those patients. The other strategy hospitals have used to meet ratio guidelines is to replace registered nurses with licensed practical nurses and have only one register nurse on each shift as a charge nurse.
Under California law, nurses are considered registered or licensed practical nurses. HB0485 prohibits this by stating the nurse ratio can only be made up from registered nurses. Supporters of nurse-to-patient ratios believe that these types of laws will recruit more individuals into the field and retain our current nurses. According to CNA President Deborah Burger, the ratio law is a mafor reason why more nurses are coming into California and why RN’s are staying at the bedside. (Anonymous, 2005) The working conditions are believed to be better when a nurse has fewer patients.
The environment is considered safer when more nurses are available to care for the patients. Nurses feel they will have more time for direct patient care and fully evaluate the patient’s needs. Individuals, who support both staffing by acuity and ratios, believe that research is needed to support both ideas. I feel that acuity is the most accurate way to determine safe ratios. At Union County Hospital, where I work, we use our acuity tool to establish a level for each patient. This is nursing staff’s first indicator of needed staffing levels. We also use ratios to staff.
Once the acuity is finished the charge nurses takes the acuity of the patients, level of experience of the oncoming shift and also our staffing matrix into consideration and staffs the next shift appropriately. I did a simple study recently and based on our staffing matrix that the charge nurse can take up to three patients and each additional staff nurse should not routinely take over six patients, we met the staffing matrix 84% of the time. Of that 84%, only 12% of the time did the acuity call for different staffing levels and most of that was that the acuity actually called for less staff.
We are a for-profit hospital and as a manager I have to validate our staffing to the CFO on a weekly basis. I asked the nurses to accurately and honestly complete the acuity, keep our matrix in their mind, and make the best decision for the patients. I also ask that if there are any circumstances that influenced their decision they should leave note of this on the daily staffing sheet. I think that acuity and ratios complement each other when used together, but one size does not fit all in nurse staffing models.
Lawmakers and hospital administrators should not be making these decisions for nurses, the bedside nurse should be able to make an individualized staffing plan for each shift based on the patients on the unit. References Allen, L. (2008). The Nursing Shortage Continues As Faculty Shortage Grows. Nursing Economics, 26(1), 35-41. Retrieved March 1, 2009, from ProQuest Education Journals database. Anonymous (2005). Schwarenegger flexes muscles on nurses. Australian Nursing Journal, 12(7), 29. Retrieved March 1, 2009, from ProQuest Education Journals database. Anonymous (2005). Ratios: Savior or villain?
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