Running head: MANDATING NURSE-PATIENT RATIOS 1

The Controversy of Mandating Nurse-Patient Ratios

LaDonna D. Henderson

Frostburg State University

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MANDATING NURSE-PATIENT RATIOS 2

The Controversy of Mandating Nurse-Patient Ratios

Nurse staffing ratios are currently a major healthcare concern because inadequate ratios

can have detrimental effects on quality of care and patient safety. According to the Agency for

Healthcare Research and Quality (2004), hospitals with low staffing levels tend to have higher

rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract

infections. Research by Cimiotti, Aiken, Sloane, and Wu (2012) found a significant correlation

between nurse-patient ratio and the development of catheter-associated urinary tract infections

(UTIs), indicating that adding one patient to a nurses average workload was associated with an

increase of one infection per 1000. Costs associated with that one extra infection have a great

financial impact, as the Centers for Medicare and Medicaid Services decided in 2008 to no

longer reimburse hospitals for treatment costs related to caring for patients with hospital-

acquired infections such as UTIs, surgical site infections, and infections associated with the use

of invasive devices such as central lines and ventilators (Kennedy, Greene, & Saint, 2013, p.

519). These infections cost $10 billion dollars per year and affect nearly a half million patients a

year (Goodman, 2013).

At the core of quality nursing care is safety, for both nurses and patients. In order to

accomplish this, it is necessary for hospitals to maintain safe nurse-patient ratios. Every one

additional patient added to a hospital staff nurses workload is associated with a seven percent

increase in hospital mortality (Department For Professional Employees AFL-CIO, 2014).

Identifying and establishing the appropriate nurse-patient ratio is critical in being able to provide

safe quality care. However, defining just what constitutes a safe ratio has come under much

debate in the past several years. Current legislation in both the Senate (S.864) and House of

Representatives (H.R. 1602, H.R. 2083) seeks to establish a federal standard for safe nurse-to-
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patient staffing ratios in acute care hospitals, setting a maximum number of patients for which

nurses would be allowed to care during a given shift (Garner, 2016). The congressional bills

limit the number of patients that can be assigned to a direct care registered nurse based upon the

particular kind of unit.

1 patient: Emergency trauma and operating rooms

2 patients: Critical care units (including NICU, emergency critical, ICU, labor and

delivery, coronary care, acute respiratory, post-anesthesia, and burn units)

3 patients: Emergency room, pediatrics, step-down, telemetry, antepartum, and

combined labor, delivery, and postpartum units

4 patients: Medical-surgical, intermediate care nursery, acute care psychiatric, and

other specialty units

5 patients: Rehabilitation and skilled nursing units

6 patients: Postpartum (3 couplets) and well-baby nursery units

Two basic schools of thought exist for determining safe nurse-patient ratios legislative

and nurse driven. Senate bill S.864 and House bills H.R. 1602, as noted above, identify unit-

based specific nurse-patient ratios. According to the ANA, California is the first and only state

that stipulates in law and regulations a required minimum nurse to patient ratio to be maintained

at all times (2015). Fourteen states have addressed the issue of nursing ratios but with no clear

definition and another seven states require hospitals to have staffing committees to plan and

implement hospital policies addressing adequate staffing. Interestingly, federal legislation does

exist that addresses staffing ratios in hospitals that are certified to receive funding from

Medicare. The 42 Code of Federal Regulations (482.23b) requires these hospitals to have

adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other
MANDATING NURSE-PATIENT RATIOS 4

personnel to provide nursing care to all patients as needed" (U.S. Government Publishing Office,

2014). Unfortunately, because the language used is too ambiguous, they fail to provide any clear

direction in establishing practical guidelines.

House bill H.R. 2083, the Registered Nurse Safe Staffing Act of 2015, represents an

alternative to federally established nurse-patient ratios by acknowledging the importance of

nursing input into safe staffing and recommending the establishment of nurse driven staffing

committees which create staffing plans that reflect the needs of the patient population and match

the skills and experience of the staff (American Nurses Association, 2015). The American

Nurses Association (ANA) supports this approach as it allows for flexibility and specificity to a

particular units needs including patient acuity level and experience level of available nursing

staff; available resources, technology and equipment; number and makeup of ancillary staff; and,

even the physical layout and space restrictions of the unit. Other factors that should be

considered when implementing nurse-patient ratios include the number of RNs, their level of

education, and reliance on the use of float nurses (nursing working on units outside their usual

scope of experience) or agency nurses (Washington State Nurses Association, 2013).

Proponents of federally mandated nurse-patient ratios argue that such legislation will

improve overall hospital working conditions for nurses as well as provide safer care for patients.

Patient safety is a core component of proposed laws to regulate the number of patients for which

a nurse can reasonably and safely provide necessary care. Research demonstrates a direct inverse

correlation between higher nurse-patient ratios and patient mortality, hospital-acquired

infections, improved patient outcomes, and patient satisfaction (Hertel, 2012, p. 4). With

healthcare reimbursements being tied to performance on patient satisfaction scores, regulating

nursing ratios increases the probability of a profitable fiscal outcome.

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Conversely, allowing the government to establish nursing ratios may put hospitals in a

disadvantageous position. Not all hospitals are created equal. What is successful for hospitals in

one area of the country may be a detriment to hospitals in another. Some areas have a shortage of

nurses to fill available positions. When hospitals do not have enough experienced nurses to

comply with the regulations, costs may be cut elsewhere in order to meet the requirements.

When staffing is inadequate, there are no nurses on white horses to ride to the rescue (Lampert,

2013); something must give. Fixed ratios do not allow for consideration of inadequate resources

other than nursing personnel.

Our aging society further complicates the need to clearly define adequate nurse-patient

ratios. The older generation is reaching an age where medical problems are more complex and

chronic conditions require increasing hospital admissions. Patients who once would have been

cared for in an intensive care setting are now being cared for on medical-surgical units.

Additionally, changes in hospital care, such as the use of advanced medical technology and

decreased length of stay has increased the amount of care each patient requires during their

hospital stay. In the past 20 years, inpatient length of stay has decreased from a week or more to

3 days or less. Patients are not less sick and there is less time for nurses to provide the care and

education necessary for a positive outcome. (Agency for Healthcare Research and Quality,

2004).

The financial climate of todays healthcare plays a role in the need for adequate nurse

staffing. While healthcare costs continue to rise, the reimbursement rates are decreasing. As

stated earlier, the amount of reimbursement a hospital receives is directly linked to how satisfied

patients report they are with their care. In 2012, under the Affordable Care Act, total Medicare

hospital reimbursements were cut by 1%. Hospitals who had high patient satisfaction scores,
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however, could recoup this loss and even receive bonuses. Research shows that the quality of

nursing care has an impact on patient satisfaction scores. Nurses have the greatest amount of

interaction with patients. The time they are able to spend with them impacts how satisfied they

are with their care and consequently how they rate the hospital. Patient satisfaction scores are not

a true indicator of quality care, and unfortunately nurses are often blamed when patient

satisfaction scores are low. A patient highly satisfied with his nursing care may complain about

other unrelated patient care issues, which then translates into a low score for the hospital. Below

is an example.

Patients have complained on the survey, which in previous incarnations included

comments sections, about everything from My roommate was dying all night and

his breathing was very noisy to The hospital doesnt have Splenda. A nurse at

the New Jersey hospital lacking Splenda said, This somehow became the fault of

the nurse and ended up being placed in her personnel file. An Oregon critical-

care nurse had to argue with a patient who believed he was being mistreated

because he didnt get enough pastrami on his sandwich (he had recently had

quadruple-bypass surgery). Many patients have unrealistic expectations for their

care and their outcomes, the nurse said (Kenen, 2015).

Changes in identifying and establishing appropriate staffing ratios have been a long time

coming, but while a great majority of research studies support the importance of mandated ratios,

not all research has reached the same conclusion (Hertel, 2012). Some have pointed toward the

costs of implementing such changes. Determining nurse staffing needs is a complex and

potentially financially burdensome problem. The perceived costs of needing to hire more nurses

or use costly nursing agencies to fulfill the staffing expectations has some people balking at
MANDATING NURSE-PATIENT RATIOS 7

mandated nurse-patient ratios. Most research, however, indicates that safe-staffing ratios are

actually cost-effective. A study reported in the Journal of Health Care Finance reported that

increased nurse staffing did, indeed, increase operational costs for hospitals; however, it did not

decrease the hospitals overall profitability (Department for Professional Employees AFL-CIO,

2014).

Another reason for resistance to change is the fact that introducing politicians into the

equation only increases the complexity of an already difficult situation. (Tevington, 2011, p.

266). It is difficult to develop comprehensive legislation due to the variety of factors that affect

staffing needs, and politicians may not have the same mindset when attempting to solve these

problems as those on the front lines. Nurses are in the trenches every day and know the

difference a reasonable patient load makes on their ability to provide excellent care for their

patients. A lawmakers perspective is much different. Passing legislation with often far-reaching

ramifications on nurses, hospitals, and patients can be dangerous without the right kind of

information. However, as recognized by the ANA, when health care employers fail to recognize

the association between RN staffing and patient outcomes, laws and regulations become

necessary (American Nurses Association, 2015).

Both intra- and interdisciplinary considerations impact the success of nurse staffing. It is

important to have a sufficient number of permanent unit nurses to provide adequate staffing.

Permanent staff provides stability for the unit and continuity for the patients. Heavy reliance on

agency or float nurses who are less familiar with the unit milieu can have a negative impact on

quality of care and patient safety.

Interdisciplinary components of nursing include the hospital climate, physician-nurse

relationships, and the availability of appropriate resources (Cimiotti, 2012). Interdisciplinary

MANDATING NURSE-PATIENT RATIOS 8

collaboration is defined by Colluccio and McGuire (1983) as a joint decision-making and

communication process among healthcare providers with the goal of satisfying the needs of the

patient while respecting the unique abilities of each professional involved in the care. Important

attributes of this collaboration include trust, knowledge, mutual respect, good communication,

cooperation, coordination, shared responsibility, and optimism (Arcangelo, et al., 1996).

Today's best healthcare environments take advantage of interdisciplinary teams to manage the

care of complex patients.

Establishing safe nurse-patient ratios has a direct effect on the nursing profession, impacting

the safety of both nurses and patients. Inadequate staffing affects the physical and mental health

of nurses and can cause job dissatisfaction and job burnout, even prompting nurses to leave

healthcare entirely. Working long hours without adequate staffing increases nurses risk for

injury, hypertension, and depression. Working too many shifts under these circumstances can

eventually lead to burnout. As reported by the Department for Professional Employees (2014), a

study in the Journal of the American Medical Association found that each additional patient

over four per nurse carries a 23 percent risk of increased burnout and a 15 percent decrease in job

satisfaction.

Patient safety is at the core of the nursing profession. The Registered Nurse Safe Staffing

Act of 2015 concludes, Patient safety in hospitals is directly proportionate to the number of

registered nurses working in the hospital. Higher staffing levels by experienced registered nurses

are related to lower rates of negative patient outcomes (including death). Patient safety is

negatively affected when nurses are overworked. An unsafe nurse-patient ratio ultimately leads

to poor quality care, increased hospital admissions, and increased adverse and sentinel events.

Nurses with heavy workloads report more frequent medication errors and patient falls. The Joint
MANDATING NURSE-PATIENT RATIOS 9

Commission (2002) reported that 24% of reported hospital sentinel events (unanticipated events

that result in death, injury or permanent loss of function) were attributed to nurse staffing

levels.

Nursing as a profession has changed and transformed many times throughout history, but

one thing has remained constant nurses provide care to maintain health and decrease pain and

suffering. This common mission unites us as a profession. Nursing today has become more

complex as nurses take on greater responsibilities in caring for a more complicated patient

population. Nurses are becoming increasingly specialized within an expanded and diverse

healthcare arena. Advanced nursing education is empowering nurses to become leaders and

frontrunners in a profession that is highly organized, nationally certified, and politically active.

The distinction of nursing as a profession is important because it reflects the value society

places on the work of nurses and the centrality of this work to the good of society. (Nursing

standards, 2010). As nursing professionals, we remain dedicated to advancing in our roles as

caregiver and advocate and seek to make a positive difference in the lives of those we serve.

While our roles as nurses are ever evolving, we are truly professionals who hold ourselves to the

highest standards both professionally and personally.

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References

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http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html

American Association of Colleges of Nursing. (2016). Hallmarks of the professional nursing

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American Nurses Association. (2015, April 29). ANA commends introduction of the registered

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Arcangelo, V., Fitzgerald, M., Carroll, D., & David, J. (1996). Collaborative care between nurse

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Department For Professional Employees AFL-CIO. (2014). Safe-staffing ratios: Benefiting

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