It is not uncommon to find the phrase “quality care” incorporated into most hospital mission, visions or value statements. This idea is ingrained into their cultures and is the idea upon which the foundation of most healthcare organizations is built. Neither is it uncommon to find the problem of registered nurse (RN) understaffing permeating these organizations and jeopardizing the health and safety of thousands of patients each year. Hospitals are in fierce competition with one another and other healthcare providers to attract and retain nurses during a time when this country is facing a nursing shortage of almost epidemic proportions.
In the year 2005, the United States had an estimated 126,000 unfilled nursing jobs. That number is expected to reach 400,000 by the year 2020. Although these jobs are going unfilled, people continue to require medical attention and as a result registered nurses are forced to care for an increasing number of patients at one time. Increased workloads lead to career dissatisfaction and burnout further aggravating the problems caused by understaffing and the resultant high patient to nurse (PTN) ratios (Rothberg, Abraham, Lindenauer & Rose, 2005).
Safe patient to nurse ratios improve patient outcomes and ensure the provision of quality care in healthcare organizations. The value of planned human resource activities designed to help organizations recruit and retain a sufficient number of nurses to meet quality assurance goals cannot be ignored. Nurses nationwide seem to share the common belief that hospital nurse staffing levels are usually inadequate to ensure safe and effective care for patients. Registered nurses report that they’re spending less time taking care of increasingly sick patients and as a result safety and quality care are suffering.
Their belief is backed by several research studies. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 24% of the 1,609 sentinel events (unanticipated events resulting in injury, death, or permanent loss of function) were directly related to nurse staffing. In 2001, 75% of nurses surveyed in the US stated that increasing PTN ratios posed a threat to patient safety. In Massachusetts, 29% of nurses surveyed had first -hand knowledge of a patient death that resulted from understaffing.
More than 50% of physicians felt that nurse understaffing is a significant cause of medical errors (Rothberg, Abraham, Lindenaur & Rose 2005). The link between patient outcomes and nurse staffing is becoming more and more evident with several research studies to validate this belief. One study reporting on findings from 168 US hospitals found that 23. 2% of the 232,342 patients studied experienced what they defined as a major complication that was not present upon admission. Of that 23. 2%, 2% died within thirty (30) days of admission. That means that 4,533 patients died, apparently from complications that developed after admission.
Among the patients studied there was a clear correlation between PTN ratios upon admission, mortality and failure to rescue which is defined as mortality following complications. This study further implied that the likelihood of patient mortality increased by 7% for each additional patient added to the nurse’s average workload. The difference from four (4) to six (6) patients per RN increased the risk of mortality 14% and the difference from four (4) to eight (8) patients per nurse was accompanied by a 31% increased risk for mortality.
With this study comes the implication that mortality rates could decrease substantially simply by increasing registered nurse staffing and thereby lowering PTN ratios (Aiken, Clark, Sloan, Sochalski & Rose 2002). Patients in one hospital ICU were found to be at a greater risk for complications caused by human error and hospital acquired infection (HAI) during times when the PTN ration was higher. The mortality rate for these patients was also found to be twice as high with the odds of mortality increasing as the patient to nurse ratio increased.
For clarification, mortality is defined as death in the ICU prior to discharge from the hospital. Understaffing exposes patients to risks such as insufficient time for clinical procedures to be done properly, inadequate training and supervision of staff, medication errors, HAI and overcrowding (Mordi, Hau, Warden & Shearer, 2000). Understaffing also leads to higher incidents of meticillin-resistant staphylococcus aureus (MRSA) in hospitals. Outbreaks of MRSA and other hospital acquired infections have been reported in ICU’s and neonatal care units during periods of understaffing.
A hospital’s ability to successfully deal with such outbreaks is directly correlated with PTN ratios. It has been predicted that over 25% of HAI in ICUs could have been prevented with lower PTN ratios. It has also been estimated that over a fourth of HAI’s could be avoided in ICU’s by keeping to a PTN ratio of 2:2 with a ratio of 2:1 being recommended (Clements, Halton, Graves, Pettitt, Morton, Locke & Whitby, 2008). Not surprisingly understaffing in neonatal nurseries contributes to the spread of infectious disease among neonates.
One investigation found a clustered rate of staphylococcal infection that was sixteen (16) times greater after periods when the infant to nurse ratio was 7:1. Infection rates were seven (7) times higher when the nursery census reached thirty-three (33). While other factors such as bathing with hexachlorophene also appeared to have an impact on infection rates, the correlation between PTN ratio and infection rates was evident. Periods of overcrowding leads to understaffing and understaffing tends to result in decreased hand hygiene compliance resulting in higher HAIs (Haley & Bregman, 1982).
Factors such as high staff turnover, staff burnout, absenteeism due to burnout and the level of importance placed on staff satisfaction all contribute to the problems of understaffing and are thus simultaneously associated with the incidence of HAI and negatively impact quality of care. MRSA increases the workload of nurses and infection control practitioners, increases patient days in the hospital and decreases nurse availability due to nurse absenteeism as a result of having contracted or been exposed to MRSA (Clements, Halton, Graves, Pettitt, Morton, Looke & Whitby, 2008).
Therefore the rising incidence of MRSA and increasing number of outbreaks within healthcare systems only serves to increase the problem of overcrowding and understaffing and negates any benefit gained from attempts at increasing throughput and decreasing workforce (Haley & Bregman, 1982). A higher number of hours of care provided by registered nurses have been found to be associated with lower rates of pneumonia and failure to rescue which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal (GI) bleeding, sepsis or deep venous thrombosis.
A higher proportion of hours of nursing care provided by registered nurses per day are associated with better care and fewer deaths for hospital patients (Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, 2002). One government study found a strong relationship between hospital staffing and urinary tract infections, pneumonia, upper GI bleeding and shock. This study found that having more nurses working at a given time was associated with a 3-12% reduction in complications experienced by patients.
Having too few nurses leads to an inadequate amount of time to ensure clinical procedures are performed appropriately, limited availability of equipment and premature discharge from ICU. In addition, having a shortage of nurses typically leads hospitals to hire outside agency nurses that may not attend mandatory trainings resulting in a nursing staff that is ignorant of hospital procedure and safety issues thereby exposing the patients to greater risks (Miller, 2004).
In spite of the startling statistics showing the obvious correlation between patient safety and PTN ratios, there is no federally mandated PTN ratio. However, some states such as California have adopted such a measure. In 2002 California passed legislation mandating a minimum PTN ratio and at least 12 other states are following suit (Rothberg, Abraham, Lindenauer & Rose, 2005). The California legislation went into effect in 2003 and required that hospitals have PTN ratio of 6:1 for its medical and surgical patients with the ratio eventually being moved to 5:1 (Aiken, Clarke, Sloane, Sochalski & Silber, 2002).
A hospital has “a duty to use reasonable care in the maintenance of safe and adequate facilities and equipment, to select and retain only competent physicians, to oversee all persons who practice medicine within its walls as to patient care, and to formulate, adopt, and enforce adequate rules and policies to ensure quality care for the patients,” (Miller, 2004, p. 3). Mandating high PTN ratios breaches this duty at every possible opportunity. Increased patient infection rates and patient mortality due to understaffing are not problems isolated to the United States.
In a study conducted at a hospital based hemodialysis unit in Saudi Arabia it was found that patients in groups with higher PTN ratios had a significantly higher risk of Hepatitis C. The study further found that understaffing played a major role in the transmission of Hepatitis C in hemodialysis units and suggests that reducing the PTN ratio is a key component in reducing patient risk for Hepatitis C, which is a major cause of morbidity and mortality in patients on long term dialysis. Understaffing during emergency situations may result in failure to adhere to universal precautions as a result of time constraints and exhaustion.
Failure to change gloves between patients when performing dialysis treatments and failure to wash hands between patients during emergency situations have all been found to further contribute to the problem (Sexana & Panhotra, 2004). The problem of understaffing also exists in the United Kingdom where higher patient admission rates coupled with bed reductions has led to stressed systems and the inevitability of understaffing and associated HAI (Clements, Halton, Graves, Pettitt, Mortan, Locke & Whitby, 2008).
The requirement that nurses work longer shifts and put in overtime has become more commonplace as hospitals try to devise ways to deal with the nursing shortage. With nurses working long, if not unreasonable hours a number of problems have arisen simultaneously that have created hazardous conditions for patients in hospitals due to the receipt of substandard care. High patient acuity levels coupled with rapid admission and discharge cycles and a shortage of nurses pose serious challenges to patient safety.
The length of time a nurse works in a single shift, the total number of hours worked each week and the amount of overtime all increase the likelihood of nursing errors that pose a serious threat to a patient’s health, safety and well-being. The potential for errors was three times higher when nurses worked twelve and a half (12. 5) hours or more with that likelihood beginning to increase after shifts that exceeded eight and a half (8. 5) hours (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Working overtime increased the odds that a nurse would make at least one error.
Extended shifts are associated with increased and obvious deviations from the standard of care and neuropsychological deficits among nurses. Medication errors such as providing medication to the wrong patient, giving the wrong dose or administering medications via the wrong route were among the errors that increased as a result of understaffing. Extended shifts have been attributed to at least two hospital epidemics of Staphylococcus aurous due to nurse fatigue and stress resulting from understaffing (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). This problem is not limited to hospitals alone.
Nursing homes suffer from the problem of understaffing with equally alarming results. Understaffing in nursing homes endangers the health, safety and well being of residents just as understaffing in hospitals jeopardizes the safety of patients. In a report commissioned by the Department of Health and Human Services (DHHS) in 2002 it was reported that an alarming 97% of nursing homes were “severely” understaffed (Lenhoff, 2005, p. 2) endangering the lives of approximately 1. 7 million residents. In nursing homes the problems resulting from understaffing manifest in a form of neglect so severe it constitutes physical abuse.
Elder neglect is defined as “the failure of a caretaker to provide goods or services necessary to avoid physical harm, mental anguish or mental illness, such as abandonment, denial of food or health related services,” (Lenhoff, 2005, p. 2). It’s often found in nursing homes that residents suffer life –threatening decubitis ulcers, unplanned weight loss, infections, hospitalizations, malnutrition, dehydration, preventable falls, cuts, untreated medical conditions or delayed treatment of illness and fecal impactions all of which could be reduced or illuminated with proper nurse staffing (Lenhoff, 2005).
Patient to nurse ratios underlie all quality of care issues resulting in serious deviations from the standard of care. For example, the proper standard of care for treating pressure ulcers is repositioning high risk patients every two hours which is virtually impossible without adequate staff. Nurse staffing is the primary quality of care and quality of life issue expressed by residents and their families.
Residents suffer from neglect and abuse more frequently in facilities where staff is overworked, not properly trained, under-equipped and certified nursing assistants (CNA) are poorly supervised due to the lack of available registered nurses. In addition to being overworked these employees tend to be underpaid, have poor benefits, are required to work mandatory overtime and have rigid work schedules that don’t allow for flexibility. All of these factors undoubtedly contribute to the 100% turnover rate of CNA’s and the 50% turnover rate of egistered nurses that’s common in this industry (Lenhoff, 2005). The National Citizens’ Coalition for Nursing Home Reform (NCCNHR) suggested a ratio of one (1) certified nursing assistants (CNA) to every five (5) residents during the day, one (1) CNA to every ten (10) residents during the evening shift and one (1) CNA to every fifteen (15) residents at night but no official ratio has been adopted by the Centers for Medicare and Medicaid (CMS).
The only federally mandated staffing requirement in existence for nursing homes is that there be one (1) RN at least eight consecutive hours per day, seven days per week and that there be sufficient nursing staff, to include LPN’s and CNA’s to ensure patient needs are met (Lenhoff, 2005). Although some states have adopted a minimum PTN ratio for nursing facilities in most instances it is up to each facility to decide on a reasonable and safe PTN ratio to ensure patient safety and employee satisfaction.
Although appropriate staffing is an important antecedent to quality patient care the importance of higher wages, benefits, flexible work hours, advancement opportunities and a general improvement in working conditions cannot be disregarded. Each of these factors contributes to job satisfaction and can reduce turnover rates and attract new nurses to facilities thereby ensuring a pool of trained staff is available. The attempt of hospitals to reduce spending in light of rising healthcare costs and reduced reimbursement rates is understandable.
However, increasing patient to nurse ratios jeopardizes safety and actually may not have a significant impact on the bottom line. On the contrary, some advocates of mandatory minimum PTN ratios feel that lowering PTN ratios may be financially beneficial over time due to decreased turnover, fewer complications and shortened lengths of stay. A PTN ratio of 8:1 results in the lowest cost for hospitals but unfortunately a PTN ratio of 8:1 is considered the most dangerous as it is associated with the highest rates of mortality in hospitals (Rothberg, Abraham, Lindenauer & Rose, 2005).
In spite of this most hospitals advocate for a PTN ratio of 10:1. It could be argued that this ratio is possibly more expensive because it opens the hospital to wrongful death suits that can be costly (Krause, 2004). Each decrease in the PTN ratio is accompanied by subsequent decrease in mortality rates, although admittedly it does cause an increase in nurse labor costs. However, an increase in PTN ratios results in only moderate reductions in labor costs. Increasing ratios from 6:1 to 7:1 only saves an average of $92 in labor costs which represents only 1% of total hospitalization costs.
Consequently, increasing ratios from 6:1 to 7:1 costs 1. 4 additional lives per 1000 hospital admissions (Rothberg, Abraham, Lindenauer & Rose, 2005). Advocating for more staffing to decrease PTN ratios may require higher wages to attract new nurses. In one survey, it was discovered that 65% of nurses would return to work in hospitals if there were some type of safe staffing legislation implemented (Rothberg, Abraham, Lindenauer & Rose, 2005). Some private organizations such as Kaiser Permanente in California have voluntarily implemented a PTN ratio of 4:1.
Kaiser Permenente appears to understand that this is a quality of care issue and a way of distinguishing themselves from the competition by being able to provide the quality care they promise (Aiken et al, 2002). As part of their strategic HRM practices hospitals need to be creative in coming up with ways to ensure they have an adequate staff of satisfied and motivated nurses. They must consider that by asking nurses to provide care with an unreasonable PTN ratio they are asking nurses to jeopardize their nursing license and ignore their professional ethics.
One way of respecting the needs and professional ethics nurses is the implementation of reasonable and safe PTN ratios. This could also be an important first step in increasing job satisfaction. Another possible alternative may be permitting job rotation activities allowing nurses to experience working in other parts of the hospital, working different shifts or performing some type of supervisory role to gain experience in other areas. A simple change of routine may have a positive impact on their emotional exhaustion and burnout levels.
For example, if they’re working a twelve hour shift perhaps they can do six in one area, take a break and finish up in another area. If hospitals and nursing homes realistically cannot hire enough nurses as a result of the national nursing shortage then they should consider not lowering their census goals and sending patients to another facility that may be better equipped to meet patient needs. It is understood that in some instances this may not be realistic or possible if the need for medical treatment exists and there isn’t a facility nearby that can provide the required care.
However, the apparent difficulty in doing such does not negate the need for hospitals to show that they value their nurses and respect their professional ethics. If the facility is in an area where there is a sufficient number of nurses but high PTN ratios are required due to high turnover and the organization’s inability to retain nurses then, the HR Department should investigate the reason for high turnover and build a business driven strategy that begins by identifying the major business needs (in this case nurses) and issues, considering how people fit in and what outcomes are necessary.
After obtaining this information HR systems that are focused on meeting those needs should be created. The HR Department must be involved in the strategic planning process as the organization is defining its long-term goals and describing how it will fulfill its mission. For example, as hospitals are deciding on issues such as expansions, throughput, census goals and quality assurance measures, an HR executive needs to be involved to provide information about the human resource capabilities and help managers choose realistic strategies for obtaining desired outcomes.
The HR department can provide valuable information during this stage about the local labor market and the hospitals capabilities based on current staff. A SWOT (strengths, weaknesses, opportunities and threats) analysis should be conducted identifying internal and external threats such as labor shortages, competitors wage rates and pending legislation that may have a serious impact on the hospitals operations and budget. For example, the mandatory PTN ratios legislated by California government is a significant piece of information that will affect labor costs and may require changes to the strategic plan.
As a result the budget will be impacted, a large number of new staff may have to be trained and the HR department would have to be involved in deciding how this ratio will be met. In addition, when developing the strategic plan the strengths and weaknesses of the current workforce must be considered to ensure that the organization does not attempt unrealistic goals. It may also be necessary for the HR department to provide some training to the nursing supervisors and the organizations administrative staff emphasizing that nurses are a valuable asset to the organization as well as the people and communities they serve.