Look Beyond Nurse-Patient Ratios

Nurses who advocate for patient safety often cite nurse staffing ratios as a top concern. Evidence suggests more education for nurses, not a mandated, one-size-fits-all approach to staffing, is a better way forward.

The public debate about whether mandatory nurse-patient ratios are necessary for patient safety is often framed as a battle that pits overworked nurses against faceless hospital bureaucrats who rigidly refuse nurses' demands.

The argument that such limits would be expensive and wouldn't allow hospitals the flexibility to adjust staffing according to patient needs was recently met with opposition from the Massachusetts Nurses Association/National Nurses United.

A spokesperson from the organization went so far as to call that argument "an out-and-out unmitigated lie," in a telephone interview with me earlier this month, implying that hospitals are willfully ignoring the pleas of their nurses.

But digging a little deeper into the debate reveals that not all nurses feel this way, and nurse leaders often take serious issue with the idea of a mandated, one-size-fits-all approach to staffing.

"A patient is not a patient is not a patient," says Joan M. Vitello, Ph.D., RN, NEA-BC, FAHA, FAAN, Associate Chief Nurse at Brigham and Women's Hospital in Boston. "We, as nurse leaders, decide staffing based on the needs of our patients, and the skills of our staff, and the competencies of our nurses, and that is the right way and the only way to provide patient care."

It's Complicated
Vitello was among those who gave testimony against the proposed Patient Safety Act, which "would set standards for the maximum number of patients that can be safely cared for by hospital nurses at any one time" in Massachusetts. She strongly counters the "unmitigated lie" claim, saying that nurse leaders at Brigham and Women's Hospital are constantly adjusting staffing based on patient needs.

"We do it with a patient acuity system," she says. "That's done on a day-to-day basis." Nurse leaders use a "synergy model" to make daily staffing choices based on factors such as how the needs of patients match up with the skills of the nurses, the number of new grads working on a unit, and even the physical layout of units themselves.

"It is very complex," agrees Patricia M. Noga, PhD, RN, Vice President of Clinical Affairs for the Massachusetts Hospital Association. "Everyone is unique, and you just can't come up with fixed ratios that will be applied everywhere across the board."

Instead of mandated ratios coming from legislation, nurse executives can and should make the business case for hiring more nurses when needed. Vitello says it's something she did successfully when she was CNO of a community hospital.

She says that when she came into the position, she felt that the nurse-to-patient ratio was not up to snuff. So she examined the quality and patient satisfaction data and built a business case, saying: "Here's my concern, and this is why we need more nurses."

Moreover, Vitello says, now that Massachusetts hospitals participate in PatientCareLink, a healthcare quality and transparency collaborative, hospitals with bad outcomes and poor staffing "can't get away with it."

"We can't hide behind having poor quality in our hospitals," Vitello says. "We won't be reimbursed for it. It's all about the reimbursement."

It's no secret, though, that adequate nurse staffing is a problem, and nurses often care for too many patients at once. So if mandatory ratios aren't the answer, what is?

"Value-based purchasing is the answer," Vitello says without hesitation. "Value-based purchasing has to do with quality indicators. When you hit the hospitals in their pocketbook, and it has to do with quality, they'll figure it out."

Education as a Marker
Vitello also says that when it comes to the right nurse-to-patient ratios, "there was no fixed number [of nurses] that was the magic bullet." But there is one thing that does seem to be something of a magic bullet for patient safety: Education.

Study after study shows that the more educated nurses are, the better the outcomes. And education is something that the IOM wants too, illustrated by its recommended goal that the proportion of nurses with baccalaureate degrees be increased to 80% by 2020.

"That's where we need to start pouring what little monies we have," Vitello says.

But like it or not, the question of whether maximum nurse-patient staffing ratios should be mandated by law may go before Massachusetts voters in November. With that in mind, Vitello says it's up to nurses and nurse leaders to show the voting public that "more" doesn't necessarily mean "better."

"I think it's going to be incumbent on nursing… to educate our public that this is a recipe for waste," she says.