Evidence Base : Impacts of High Nurse to Patient Ratios - Research Paper Example

?Evidence Base Research: Impacts of High Nurse to Patient Ratios Introduction There is a substantial amount of evidence based research that highlights that patient outcomes are poorer, infection rates go up, and failure to rescue increases when nurse to patient ratios are high both in telemetry (Amaravadi et al, 2000; Archibald et al, 1997; Clarke, 2003) and surgical units. There is also chance of nurse burn out, job dissatisfaction, and low retention (Decker, 2008; Brown, 2010). The high nurse to patient ration, while serving cost cutting requirements, forces nurses to be focused more on quanitity of care than quality of care, and may lead to negative outcomes for both patients and nurses. In the United States, there are no standard ratios established by Federal legislation, and only California State has set a standard list of ratios for different nurses and units (Brown, 2010). The decision regarding the nurse to patient ratio is left largely to the individual hospitals and units based on the populations that they serve, the level of acuity or the nurses’ experience and training. However, there is a chance that even these loose considerations may be overridden by budgeting and costing needs, leaving the available nursing staff over-burdened and unable to work at optimal. In the current climate of rising healthcare costs and the proposed reduction in medicare payments, nurse to patient ratio has been increased in an effort reduce operating cost. At my hospital, nurse to patient ratios have been increased for telemetry nurses to 6 to1, and for medical surgical nurses, 7 to 1.This has led to issues regarding quality of work, errors, lack of time for patients, and over work for the existing staff. This paper aims to present research that consolidates the need to have suitable nurse to patient ratios, and also which highlights the lack of standardization in the methodology through which nurse to patient ratios are decided. The paper will dwell on the existing guidelines that determine the nurse to patient ratios, and will make recommendations to develop a more targeted and accurate approach to staffing. Literature Review There have been several studies that have highlighted the adverse patient outcomes related to nursing care, and more specifically, to the nurse to patient ratio. These research have been undertaken by both governmental and non-governmental agencies and across diverse geographical regions. The available evidence from the previous studies has strongly conformed to the perception that high nurse to patient ratio is detrimental to thepateints’ health and mortality, and may also contribute to the nurses’ burnout and dissatisfaction (Konetzka, Stearns and Park, 2008). This section presents a review of the available research that has linked high nurse to patient ratio to diverse detrimental outcomes. In a research conducted across using survey of nurses, pateints and 168 nonfederal adult general hospitals’s data in Pennsylvania, it was found that nurse to patient ration has a direct impact on patient mortality and emergency rescue. The researchers found that there was an increased likelihood of 7% odds increase in the chance that a patient would die witin 30 days of admission, as well as a 7% increase of the odds of failure-to-rescue. The researchers also reported that there was a 23% increase in the odds that the nurses suffer from burnout, and 15% increase in chances that they suffered from job dissatisfaction when there was an increase of patient per nurse (Aiken et al, 2002). These findings strongly indicate that the nurse to patient ration is crucial factor for patient helath and mortality and for the well being and productivity of the nurses. In another research undertaken in acute care settings in non-federal hospitals in Maryland, it was found that there was a significant increase in risk of postoperative pulmonary and infectious complications in patients who had undergone esophageal resection, in cases where patient to telemetry nurse ration at night time was more than 2:1 (Amaravadi et al, 2000) Similarly, several researches have found that there is an increase in urinary tract infections (UTI), pnemonia, upper gastro-intestinal bleeding, shock, falls, pressure ulcers and longer hospital stays (Stanton, 2010). In an early research, understaffing of nurses was found to correlate with increased incidences of staphylococcal outbreaks among neonates and infants in hospital nursery (Haley and Bregman, 1981). A relatively recent study conducted in general pediatrics wards in Toronto, Canada, it was found that the patient to nurse ratio had a direct impact on the rate of nosocomial viral gastrointestinal infections (NVGIs) (Stegenga ,Bell and Matlow, 2002). Other research have also found that nosocomial infection risk in a pediatric cardiac intensive care unit increases with lower nursing staff strength (Schnelle et al, 2004). In a new study conducted across 46 hospitals in England, the researchers found that the telemetry nurses who were responsible for nine or more patients were unable to spend quality time with pateints (time spent in talking, teaching or comforting the patients) and that they were more liable to make errors (Santry, 2011). In a similar survey condcuted among nurses in Nevada, USA, it was found that out of the 77 respondents, 60 stated that conditions in the hospitals have gone worse owing to the increasing number of pateints and staff reduction (Nevada Nurses Association, 2006). The survey also revealed that the majorit of the nurses believed that a better nurse to patient ration would lead to quality interaction, better charting and teaching moments, more efficiency in work and better overall results to health care. The nurses also revealed that owing to over work, they worry about losing patients or making errors. Some of the reasons that were quoted in this survey as the causes of low nurse ration included lack of initiative of the hospitals to recruit, lack of motivation and bad working conditions and hence high staff turnover (Nevada Nurses Association, 2006). A recent study found evidence that supported that the low nurse to patient ratio (matching those in California) would lead to 14% lower number of surgical deaths in hospitals in New Jersey and 11% less in hospitals in Pennsylvania (Brown, 2010). This research provides conclusive comparitive evidence on the positive gains that a better nurse to patient ratio could entail. While there is very little research available on the specific errors or disadvantages that can occur in telemetry nursing owing to high nurse to patient ration, self-reports from nurses indicate that the situation is dire, especially as patient acuity is on the rise and often ER and ICU nursing is full and do not entertain patients who may need it (Howe, 2007). For example, there have been incidents reported that highlighted the fact that telemetry nurses can be caught up serving an emergency case (due to lack of beds in ER/ICU) while neglecting the other patients assigned to them (Nursing Forum, 2007). There is also some evidence from independent research that has established that the nurse to patient ratio for surgical units needs to be lower than in telemetry (Valda et al, 2007). The discussion provides substantial and extensive evidence of the impact of nurse to patient ration across various hospitals, countries and specialist areas. In adidtion to accepting that there is a correlation between nurse to patient ratio and patient outcomes, it is also essential that the appropriate nurse to patient ratios be established for specific wards and units. The available research in this area is however rare and inconclusive, as diverse methodologies and interpretations are adopted by different researchers. There is little centralized approach to researching what constitutes the optimum ratio, as several researchers have worked in individual capacity using different perspectives to determine what constitutes patient outcomes, nurse workload and even what is meant by nurse ratios – nurse per resident day or nurse per resident patient, or nurse per bed. Moreover, there have been inconclusive and often opposing findings when the nurses dissatisfaction levels are measured as an output of high nurse to patient ratio. While in most of the studies it has been found that nurses are dissatisfied with the working conditions (and this is cited as the reason for high turnover, professions switching by nurses), the studies are not directly and conclusively link the nurse dissatisfaction with nurse to patient ratios. Additionally, there have been several studies that have explored the use of management techniques to motivate nurses (Tzeng, 2002; McNeese-Smith, 1999; Christensen, Lee and Bugg, 1979; Henderson, 1995) and also FCMPN techniques to reduce burnout (Scott et al, 2010a, Scot et al, 2010b), which have posted succesful results without altering the nurse to patient ratio. The Federal legislation on nursing staff recruitment and nurse to patient ratios leave much to be desired as these leave the onus of staffing on the management of the local hospitals (Feuerberg, ). It is expected that hospitals and units are in the best position to assess the staff requirements based on their workflow, patient acuity and staff experience. Standardized Guideline for Evidence-Based Project In my unit, nurse to patient ratios have been increased for telemetry nurses from 5 to 1 to 6 to1, and for medical surgical nurses, 7 to 1. While 5:1 itself was difficult to manage, a ratio of 6:1 appears to be outright dangerous for patient safety, as nurses find themselves unable to give attention and time to all the patients. Revisions and Suggestions The above changesin the hospital are not based on empirical research, and hence there is a need to reassess the ratios. It is understandably a very complex area as finding out what rations are appropriate depends on the total population that a facility serves, the expertise and experience of the nurses, the type of patients that the nurses are serving and a variety of other factors. There is therefore need to conduct more targeted research that could highlight the factors and the weights that need to be given these factors in specific situations in order to understand what nurse to patient ration are needed. One starting point to make suitable changes is to follow the guidelines provided by the Federal legislations, and to some extent by the State of California. While there is no set standards, it is considered appropriate by the Centre for Medicare and Medicaid Services (CMS), that there need to be 2.4 - 2.8 hrs/resident day for nurse aids, 1.15 - 1.30 hrs/resident day for licensed nurses 0.55 - 0.75 hrs/ resident day for registered nurses, depending on nursing home population. In addition, Federal legislation makes it mandatory that there are 8-hours of registered nurse and 24 hours of licensed nurse per day (Feuerberg, ). California has established 1:1 in operating room, 1:2 for intensive care, telemetry, 1: 4 in paediatric. It is clear from these statistics that the current nurse-to-patient ratios in my hospital fall much higher than the recommended by CMS, or mandated by the State of California. Moreover, by experience, it is seen that managing 6 patients at any given time is detrimental to the safety of the patient in my hospital. It is therefore recommended that the nurse to patient ratio should be revised. This revision is however recommended to be based on internal research and survey or nurses. As a starting point, the following steps can be implemented. 1. Assess the Nurses reports of errors, concerns specifically regarding the number of patients that they have to look after in telemetry. This will be able to provide an assessment of the work load, difficulties and the scope of patient errors that may arise due to the current nurse to patient ratios. 2. Assess the perception of the patients regarding rounding and availability of nurses with the current nurse to patient ratios. This is an adequate measure of the quality of care (Upenieks et al, 2007). 3. Develop an optimal number of nurse to patient ratio based on reduction of errors and increase in quality care. Conclusions Using evidence based information, it is seen that a high nurse to patient ratio has a detrimental impact on the well-being and even the mortality of the patient. While it is debatable what is the best or the standard ratio that can be assigned to specific nursing units, and also what methods need to be employed for this selection, there appears to be a universal agreement that lower nurse to patient ratios will result in all around benefits. It is therefore recommended that in my hospital, there is an immediate need to modify the nurse to patient ratios and to develop a more appropriate ratio based on an empirical assessment of the nursing errors, patients’ perception of quality care and nurses’ opinions. References Aiken, L., Clarke, S. P., Sloane, D. M. and Silber, J. H. (2002).Hospital Nurse Staffing and Patient Mortality,Nurse Burnout, and Job Dissatisfaction. Journal of American Medical Association, 288(16):1987-1993 Amaravadi, R. K., Dimick, J. B., Pronovost, P. J. and Lipsett, P. A. (2000).ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. 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