The past decade has been a turbulent time for US hospitals and practicing nurses. News media have trumpeted urgent concerns about hospital understaffing and growing hospital nurse shortage. Nurses nationwide consistently report that hospital nurse staffing levels are inadequate to provide safe and effective care. Physicians agree, citing inadequate nurse staffing as a major impediment to the provision on high quality of care (Carlson 2010). The shortage of hospital nurses may be linked to unrealistic nurse workloads. Forty percent of hospital nurses have burnout levels that exceed the norms of health care workers.
Job dissatisfaction among hospital nurses is four times greater than the average for all US workers, and one in five hospital nurses report that they intend to leave their current jobs within a year (Carlson 2010). The two most common nursing management styles are Team Nursing and Primary Care Nursing. Each type of nursing care management has its own pro’s and con’s with respect to both nurses and patients. Both systems were devised in order to improve the quality of care given to patients, while considering the abilities, capabilities, and limitations of nurses and other health care providers in the ward.
Primary Care Nursing is a system in which one nurse is caring for all the needs of a patient or more within a 24 hour from admission to discharge. He or she is responsible for coordinating and implementing all the necessary nursing care that must be given to the patient during the shift. If the nurse is not available, the associate nurse responsible for filling in for the nurse’s absence will provide hospital care to the patient based on the original plan of care made by the nurse.
This type of nursing care can also be used in hospice nursing, or home care nursing (Douglas 2010). The advantage of promoting primary nursing in hospital practice is that the patient is able to build trust and confidence on the abilities of the nurse assigned to him. This in turn can lead to fast recovery and improved nurse-client relationship (Nickitas 2010). The disadvantage of promoting primary nursing is the high cost setting, especially in specialized units such as the ICU where one nurse is assigned to the total care of a single patient.
It is also important that the assigned nurse will be highly knowledgeable about the patient’s condition and how to properly plan and implement the right nursing care. Also, if the right patient-nurse mix is not achieved, the patient may deteriorate in condition and even reject the nurse totally. Team Nursing, on the other hand, is a system developed in the 1950’s to answer the need of more nurses in a hospital. This is where one nurse is in charge of leading group comprising 4-6 different members such as nursing aids and unlicensed assistive personnel to care for a group of patients equating to 15-20 (Nickitas 2010).
Patient care is delivered through the coordination and cooperation of each team member through delegation of assignments with respect to the team member’s level of responsibility and accountability. Delegation of patients and duties are done at the beginning of the shift, while a summary of care given and outcomes resulting from patient care is conveyed at the end. Any action that is done by unlicensed assistive personnel, nursing aid or nurse volunteer is the responsibility and accountability of the team leader, the registered nurse.
The advantage of team nursing is that the total number of absences and leaves related to over-work and medical conditions related to stress and fatigue is lessened. This is due to the sharing of workload between each team members, enabling them to do a huge amount of work in such a short time without undue exertion. This delegation of duties will also enable team members to hone their skills in different nursing tasks, and also improve their ability to communicate and coordinate. Each can also learn from each other during team conference while discussing on ways how to go about in caring for different patients.
Once the team has established themselves as members and not as individuals each would feel that they belong thereby increasing nurse morale. This in turn would improve the quality of care each would give to the clients, leading to better patient satisfaction (Seblega 2010). Each will realize each team member’s role in caring is important for the client, minimizing the barrier between each profession. One major disadvantage of team nursing is lack of team effort and inability to communicate.
Pooling people together in order to work does not necessarily equate that each team will work as a group. Time must be given in supervising the team to help each member act as part of a group. Communication barriers may cause some problems in rendering patient care. If team members are constantly being re-shuffled, the continuity of care can be interrupted, leading to patient dissatisfaction. How do we know what is the best for our patients? California is the first and the only state to pass legislation to establish minimum nurse to patient staffing ratios for each unit in the hospital (Seblega et al 2010).
This legislation has been in effect since 2004. The California ratio law is very specific, the rules are inflexible and apply at all times for all licensed nursing staff. While other states have contemplated such proposals, none have enacted such legislation, perhaps because the logic of ratios quickly falls apart. Ongoing studies of patient care outcomes have not shown any improvement with the California approach, and in some ways, care may be even less safe. Some of the reasons why are as follows: California suffers from a shortage of nurses (Seblega et al 2010).
Some hospitals were unable to hire nurses to achieve ratios and had to use temporary, floating or traveling nurses to comply with the law. These nurses are unfamiliar with patients, units and hospitals. Mandating ratios did nothing to mitigate the severe shortage of nurses and in fact, could have worsened it. Supporting Schools of Nursing, re-entry programs, recruitment and retention campaigns might have achieved a similar outcome without the unintended consequences. Under ratios, patient “hand offs” to a different nurse are increased.
It is well documented that “handing off” a patient from one caregiver to another increases the chance of error. Ratios may force hospitals to reduce support staff in order to achieve required ratios. This is because the funds to employ more nursing staff may come at the expense of other unit-based staff that performs “non-nursing” work. An unintended consequence of the legislation is that nurses may have actually acquired more tasks and duties. More nurses are needed in hospitals. In 2006, the American Hospital Association found that hospitals need approximately 118,000 RNs.
With 49% of hospital CEOs reporting that they have difficulty recruiting nurses, it is no wonder that the national vacancy rate has risen to 8. 5% (Carlson 2010). Adequate nurse staffing is key to patient care and nurse retention, while inadequate staffing endangers patients and drives nurses from their profession. Some hospitals have had success in retaining their nurses by raising nurse-to-patient ratios, involving nurses in decision-making and providing nurses with opportunities to further their education.
The Institute of Medicine (IOM) 2002 concluded that the environment in which nurses work is a breeding ground for medical errors which will continue to threaten patient safety until substantially reformed (JACHO 2002). The study finds increased infections, bleeding, and cardiac and respiratory failure associated with inadequate nurse staffing. A 2002 report by the Joint Commission on Accreditation of Healthcare Organizations stated that the lack of nurses contributed to nearly a quarter of the unanticipated problems that result in death or injury to hospital patients.
A 2006 study by Heather K. Spence Laschinger, PhD, RN, and Michael P. Leiter, PhD, found that patient safety outcomes are related to the quality of the nursing practice work environment. Strong correlations exist between low staffing levels and increased emotional exhaustion, which leads to more patient complaints, nosocomial infections (infections received from hospital care such as urinary tract or staph infections) and medication errors.
While the most important results related to inadequate nurse staffing are unanticipated patient complications and deaths, other costs include longer hospital stays, higher rates of occupational injury and stress among nurses, more turnover among nurses, and more liability for hospitals. In 1999, the IOM estimated that preventable medical errors cost the economy from $17 to $29 billion annually, of which half are health care costs (USDL 2004).
Working long hours and with inadequate staffing also affects nurses’ health, increasing their risk of musculoskeletal injuries (MSDs—back, neck, and shoulder injuries), as well as causing hypertension, cardiovascular disease, and depression. MSDs are common among health care workers due to the cumulative effects of frequent lifting and repositioning of patients. Nurses’ aides and orderlies sustain the most MSDs of any occupation and registered nurses rank eighth among all other workers. Nurses working 12 or more hours per day and 40 or more hours per week are 50% more likely to get a back, neck, or shoulder injury.
Nurses working nights or weekends also significantly increased their risk, while nurses working rotating shifts had twice the number of reported accidents as those working day or night shifts only. Nurses’ cardiovascular health also suffers from working long shifts. There is a greater risk of hypertension and cardiovascular disease from long working hours, including higher blood pressure among workers completing over 60 hours of overtime per month and increased risk of acute myocardial infarction among those working more than 11 hours per day.
These solutions do nothing to address the underlying reason why so many qualified nurses leave the profession. Better nurse-to-patient ratios would, however (JACHO 2002). California hospital did not seek to meet the new requirements by increasing their use of LPNs. More studies will be needed to determine the effect on patient outcomes. Meanwhile, several other states have enacted or put into motion legislation addressing safe staffing levels. For instance: In 2004, New Jersey passed legislation requiring hospitals to disclose staffing information.
In 2005, Rhode Island enacted legislation requiring hospitals to annually submit a staffing plan. In 2005, Oregon updated and strengthened its 2001 legislation requiring hospitals to appoint a staffing plan committee and take other measures to ensure timely filling of vacancies. In 2002, Texas put in place similar regulations to the original Oregon staffing plan legislation. Twenty-six states, including Connecticut, New York, and Kansas, have introduced or enacted nurse-to-patient ratio legislation; several others have introduced staffing-plan bills, including Indiana, Hawaii, Massachusetts, Maryland, Vermont, Washington, and West Virginia.
If enacted, the Safe Nurse Staffing and Quality of Care Act of 2005 (Douglas, 2010) would establish federal minimum RN nurse-to-patient ratios to improve patient safety and quality of care and to address the nursing shortage that has left our nation’s hospitals critically understaffed. Other initiatives in Illinois and Tennessee attempt to counter shortages and bolster the workforce. Governor Rod Blagojevich (IL) opened the Illinois Center for nursing to assess the current statewide nursing economy and develop a plan to educate, recruit, and retain nurses.
In summary, I recommend that all proponents of mandatory, nurse-to-patient staffing ratio laws consider the alternative of improving staffing levels by reimbursing nursing care based on the intensity of the care given. In addition, a nursing intensity billing model could reestablish the link between nurses and patients. It could help nurses demonstrate the value of what they do for patients. Currently we cannot show the economic value of nurses because we lack the data to do so.
Linking nursing intensity, direct costs of care, and payment for that care within the billing and reimbursement system could profoundly change the relationship between nurses and hospitals. It could provide data needed to increase staffing levels and subsequent quality of care, and result in better hospital performance in the long run. Mandatory nurse-to-patient staffing ratios may exacerbate, rather than correct, the imbalance between patient needs and available nursing resources in U. S. hospitals because patients have different care needs. The evidence has clearly demonstrated that many factors related to nurses, patients, and hospitals create a high degree of variability in nursing intensity.
Creating a single set of national or state nurse-to-patient staffing ratios could create a situation in which some patients receive more nursing care than needed, and others less care. This could lead to lower quality of care and higher costs. Mandatory nurse-staffing ratios may exacerbate rather than correct the imbalance between patient needs and available nursing resources in U. S. In contrast, optimizing nursing intensity based on actual patient needs could address the perceived nursing shortage by creating a better fit between patient demands and the nursing resources used in the clinical setting.
Reference Carlson, J. (2010). Rallying for ratios. Modern Healthcare, 40(24), 8-9. Retrieved from Health Source: Nursing/Academic Edition database. Douglas, K. (2010). Ratios – If It Were Only That Easy. Nursing Economic$, 28(2), 119-125. Retrieved Joint Commission on Accreditation of Healthcare Organizations, Healthcare at the Crossroads: Strategies for Addressing the Nursing Crisis, August 2002. from Health Source: Nursing/Academic Edition database Nickitas, D. (2010). Re-Evaluating Nurse-Patient Ratios: Beyond the Numbers and the Law.
Nursing Economic$, 28(2), 73-93. Retrieved from Health Source: Nursing/Academic Edition database. Seblega, B. , Zhang, N. , Unruh, L. , Breen, G. , Seung Chun, P. , & Wan, T. (2010). Changes in Nursing Home Staffing Levels, 1997 to 2007. Medical Care Research & Review, 67(2), 232-246. Retrieved from Health Source: Nursing/Academic Edition database U. S. Department of Labor, Bureau of Labor Statistics, BLS Releases 2004–2014 Employment Projections, USDL 05-2276, www. bls. gov/emp.