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Does Mandating Nurse-Patient Ratios Improve Care?

Cheryl Clark, for HealthLeaders Media, January 25, 2010

As more than a dozen states consider laws to establish hospital nurse-to-patient ratios, what has been the experience in California—the first state to establish such a rule—since the policy took full effect in 2005?

Do patients get better care, experience fewer adverse events, and have shorter lengths of stay and lower mortality? Are nurses doing a better job, and by extension, are doctors and other hospital workers? And how much has the increased expense affected hospitals' bottom lines?

Unfortunately, a solid answer remains elusive. As one might expect, hospitals and nursing organizations are divided in their perception of how things are going. The California Nurses Association says the ratios have improved nurse retention, raised the numbers of qualified nurses willing to work, reduced burnout, and improved morale.

Advocates also say narrower ratios in high-intensity areas, such as the emergency room, have improved patient satisfaction and have reduced medical errors, including medication mistakes and falls.

But Jan Emerson, spokeswoman for the California Hospital Association, which fought implementation of the ratios with an unsuccessful court challenge, says they are tough for hospitals to enforce.

"The most onerous aspect to the ratios is the requirement that hospitals be in 'continuous compliance'—that means in compliance every minute of every shift on every unit every day," Emerson says.

"If a nurse steps away to use the bathroom down the hall, the regulations require he/she to reassign all the patients to another nurse. That doesn't make sense and frankly is very difficult to adhere to," she adds.

The other problem Emerson points to is with ratios in the emergency room, where the ratio is one nurse to four patients. "The only time a hospital can go above this ratio is when there is a local or state declared emergency. This rigid ratio is one of the reasons that ER waiting times can be lengthy—especially if there is an unexpected surge of ER patients because of a car crash.

"Hospitals do the best they can to predict how many nurses they will need during different parts of the day and staff accordingly," Emerson adds. "But the rigid nature of the ratio doesn't provide any flexibility when the unexpected occurs."

California's nurse-to-patient ratios, which were fully phased in by April 7, 2005, call for one nurse for every two patients in the intensive care, critical care, and neonatal intensive care units, as well as in post-anesthesia recovery, labor and delivery, and when patients in the emergency room require intensive care.

One-to-three patient ratio is called for in step down units. One-to-four patient ratio is required in antepartum, postpartum, pediatric care, and in the emergency room, telemetry, and other specialty care units.

One nurse for every five patients is required in medical-surgical units and one for every six in psychiatric units.

"We've been fighting for a similar bill in Massachusetts," says David Schildmeier, director of communications for the Massachusetts Nurses Association. He says similar legislative proposals are working their way through 13 other states as well.

"We know 90% of our nurses support and desperately want it," he says. The association in 2008 hired a polling organization to survey patients who had spent time as inpatients "and 30% said safety was compromised because nurses had too many patients."

DeAnn McEwen, an RN and member of the California Nurses Association board of directors, says the ratios have helped reverse the number of nurses exiting from the profession over the last decade because of burnout.

"Since the ratios took effect in California," McEwen says, "I don't see the big turnover of nurses that I used to see and the RN vacancy rate in hospitals has dropped dramatically."

Before the ratios took effect, she says, "Hospitals in California, in general, had a 'one-size fits all' mentality about how many nurses should work in a unit based solely on their bottom-line budget."

"Legislated standards for safe staffing provides a public safety net and hospitals are still required to staff-up from these minimums based on the acuity of the patients."

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