The Possibility of Nursing Shortages - Research Paper Example

? A Comparative Analysis of Nurse-Patient Ratio Man s For the Hospital Setting Throughout the United s there is an initiative to create mandatory guidelines regulating the exact number of nurses that must be present at all times during any hours where patients are present and under the care of medical professionals. Several large-scale investigations have demonstrated the risks involved to patients in a hospital setting with too few nurses, or nurses that are over-burdened with patient care duties. These studies have indicated that too few nurses with too many patients leads to a negative patient outcomes, in addition to lower nurse-retention, and an unattractive environment for the best nursing talent. Legislation has passed in California, and will be presented in other states to mandate a specific ratio of nurses per patient that must be maintained at all times. The goal of this study is to identify a balance between adequate levels of nurse-personnel while maintaining hospital efficiency both in terms of cost, and the time-resources of medical professionals. A Comparative Analysis of Nurse-Patient Ratio Mandates For the Hospital Setting INTRODUCTION The possibility of nursing shortages is a relevant concern for hospitalists, patients, and the general public alike. Years past have produced numerous concerns of under-staffed, overburdened hospitals as a barrier to adequate care. This paper will endeavor to examine the conventional wisdom that more patient responsibility will yield lower quality care from nurses and other healthcare professionals; and the extent to which such a decline in patient outcome can be quantified. But is is true that patients will receive better care, with fewer medical errors under a system of precise nurse-patient ratios? Are nurses doing a better job under such a system? How would such a change extend to doctors and other medical practitioners? Over a dozen states are now considering some form of mandate that will enforce specific ratios of nurses for every patient under the hospital's care, it is worthwhile to examine critically the available research on the balance between caregiver and patient. It is in the interest of everyone to seek the ideal balance between nurse staffing levels and the cost-effective management of the time-resources of medical professionals. CASE STUDY “ Celeste examined the patient's chart; she had to remind herself that Mr. McGillicuddy wasn't just a disease; he was a case of full-blown nephrotic syndrome; based on the protein-cysts found in his urinalysis, plus a chronic case of trigeminal neuralgia on top of that. Oh, and a living. breathing person. But with his age and prognosis, personhood wouldn't cut much slack with the transplant committees. The experienced Nurse was not optimistic that he would retain his living status much longer; in part because the very lab results that Celeste found so damning took as long as they did to arrive; compounding the bad news they were reporting. On the one hand, in preparation for the new regulations mandating more nurses for every medical center in the county, patients would get more attention from nurses like her; the problem being – a hospital as small as hers had to cut corners somewhere; so they'd hadn't been able to hire that new med-tech they'd been needing for months now. So the doctors were probably lucky to get their results as soon as they did – as late as it seemed to her. But adding more nurses was about to be required by law; not something she could whine about to the head-nurse. She patted Mr. McGillicuddy's hand in reassurance. Well, it would fall to her – and the new blood they were hiring to pick up the slack; make up for the corners cut...” PROS More nurses equals better care; in order to ensure the best possible patient outcomes during hospitalization, nurse-to-patient ratios must be mandated by law. The correct ratio will lead to happier nurses, and healthier patients. It seems an obvious solution; more nurses certainly can't hurt, More eyes to watch over patients, more trained hands to tend to medical emergencies and assist with procedures. A hard ratio would seem to be the most viable solution to ensure minimum standards of efficiency and care towards the overall betterment of patient outcomes. Money for the hiring is always a factor; but in some cases additional funding for compliance could be arranged by government. Supporters point to success experienced from sharper ratios in high-intensity hospital departments, like the emergency room, have resulted in improved patient satisfaction and a reduction of identifiable medical errors from fatigue, such as prescribing the wrong medication. (Clark, 2010) In fact, the California Nurses Association, which has had such mandates in place since 2005 has reported improvement in the following areas: General Morale among registered Nurses Greater numbers of qualified nurse applicants Better retention of qualified nurses Wages in California for nurses have increased since the measure was passed. (Mark et al. 2009) The California law calls for one nurse for every two patients in every critical or intensive care units, neonatal units, post-operative recovery (whenever anesthesia is involved). Specialty care units such as the emergency room, maternal and pediatric wards can get by on a 1-4 ratio. The nurse-count declines further for surgical and psychiatric care units. Adding more fuel to the fire was a study sponsored by the Massachusetts Nurses Association in which their own members favored staffing ratio requirements by as much as 90%, where a belief was expressed by 30% of the nurses surveyed that the number of patients they were assigned was sufficient to compromise treatment safety, thus the need for more nurses. (Clark, 2010) In addition, A Pennsylvanian study was conducted as an exploration of the staffing challenges inherent with modern nursing, and how these challenges translate into potential risks for patients. A random sampling of 50% of registered nurses on the state's Nursing rolls was conducted to measure satisfaction. Of these, 52% responded out of a total of 168 hospitals in the final sample. 232,342 patients were covered by the survey, in which nurse ratios ranged from 4:1 to 8:1, and under those conditions, 2% of the total patients included died within 30 days of admittance. It was concluded that four more patients per nurse should result in as many as 2000 preventable deaths over the course of the study. The study predicted the most deaths under, predictably, the 8:1 ratio. (Aiken, 2002), the investigation also employed the Maslach scale to quantify the extent of 'burnout' amongst nurses. (Maslach & Jackson, 1982) But Burnout was lower in California compared with other states as of a 2006 survey – attributed to the nurse-patient ratio. (Aiken et al. 2010) And predictably higher when a new patient was added to the workload. (7% higher mortality) (Van den Heede et al. 2009) The now well-known Pennsylvania findings have had important ramifications for the issues of nurse shortages and patient safety. The significance of this study deserves careful consideration for its ramifications for nursing staff, in terms of preventable patient deaths. The apparent correlation between the presence of nurse staffing with patient rescue during medical emergencies is illustrative of the nurses' role in health surveillance. Additions in hospital staff are also important beyond the most obvious life-saving capacity; non-critical patients are still vulnerable to adverse events or nosocomial illnesses which sufficient nursing care could prevent. Few would deny the simple equation that the Pennsylvania study plainly reveal: More nurses equals better patient outcomes. CONS Imposing arbitrary guidelines on hospital staffing creates management problems in terms of juggling nurse schedules, while costing time and money with dubious benefits. Those advocating mandatory requirements in terms of nurse-to-patient hospital staffing ratios can find supporting evidence from studies correlating patient mortality/morbidity with increasing nurse workload. Two studies in particular have been used to support development of state and federal laws. The first, among two studies commonly referred to by supporters of such a measure involved 799 hospitals in 11 states, in which a greater occurrence of infections, including urinary tract infections and pneumonia among patients. In addition, shock or cardiac arrest occurred when the nurses' workload was high. (Needleman et al. 2002). The second, well-known study documented staffing levels at 168 Pennsylvania hospitals in 1999, (mentioned above) and the subsequent mortality rates of a selection of patients receiving major surgery. The familiar report in the aforementioned section also arrived at a threshold beyond which each additional patient under a nurse's care increased patient mortality by seven percent. (Aiken et al. 2002), (Silber et al. 2002). These findings have been the essential basis for the prevailing standards governing nurse-to-patient staffing ratios. These studies have come under some criticism, the nurse-to-patient ratios used in these experiments by both Needleman and Aiken's study are hospital averages, which may not reflect specific levels of attention by nursing staff where their attention was most needed. These studies provide no basis for generalizing to any particular nursing unit or individual. Other factors may influence mortality, to an even greater extent; if the patients were involved in surgery then a negative outcome may be entirely out of the nurses' hands; or the surgeon, or other agents in the hospital were equal contributors in the final fate of the patient. But those are older studies. The attention garnered by them has prompted a new round of investigations relevant to current hospital conditions and the questions of mandatory nurse staffing. While an investigation of approximately a hundred nurse staffing studies by the Agency for Healthcare Quality and Research found a connection between nurse staffing levels and patient mortality, it was concluded that these relationships are not directly causal, at least with respect to the nurses. (Kane et al. 2007). The available evidence does not make clear a specific, ideal nurse-to-patient staffing ratio presently. Obviously, no one wants frazzled, over-worked/under-paid slip-ups constantly making mistakes, but there is still uncertainty about what the golden ratio of patients to nurses should be. Present literature contradicts the legislative attempts from those who believe in rigid nurse-to-patient staffing ratios. The American Hospital Association (AHA), in association with member state associations, has been adamant in its opposition towards laws mandating any specific nurse-to-patient fixed ratio. They are of the opinion that nurse-to-patient staffing ratios impede scheduling flexibility, and impose staffing restrictions artificially. Presently, there is no direct evaluation of nursing 'magnitude' and how it affects patients in terms of a cost-benefit analysis. Only a single mean cost of nursing per patient, per day. A lack of added compensation to the hospital serves to discourage staffing increases without some clearly attributable benefit or necessity. In fact, A 2006 study has found that the average amount of time needed to treat a patient with a given diagnosis was subject to wide variance. (Welton, et al. 2006). The 'Intensity' of Nursing, in addition to financial costs is also subject to similar variance; not only across multiple sections of the same hospital, but within the same ward or unit as well. Patients' age, comparative health and presence or absence of senility are also factors. (Welton, Unruh, & Halloran, 2006) These factors and uncertainties combine to create a climate among clinicians of strong resistance to mandatory staffing legislation. Organizations such as the American Organization of Nurse Executives has expressed opposition towards fixed ratios. They desire improvements in nurse monitoring, recruitment and retention initiatives, and advances in undergraduate nursing education (American Organization of Nurse Executives, 2003). Some believe that the idea that mandatory staffing is necessary stems from recruitment shortfalls. For instance, a typical mid-sized hospital that normally retains approximately 100 adult surgical patients. An increase of a single hour of bonus care from a qualified, registered nurse each day at the rate of $40 per hour would increase costs by $4,000 per day, totally in $1.4 million more dollars per year. Nor would there be any apparent, additional revenue for The hospital that provides this extra patient care. This is important for comprehending the root factors determining the billing and cost underlying nursing and intensive care. (Clark, 2010) CONCLUSION It is undeniably in the interest of all parties, doctors, nurses, patients – indeed anyone who wants the option of quality medical care, to not only address management/administration issues in the hospital setting; but also to commit ourselves to a strategy that will encourage ongoing improvement of the governance of the hospital whenever, and wherever possible. It is not simply the medicine itself that we must concern ourselves with; a host of minute details involving patient care, resource management, medical surveillance, and patient rescue all contribute to the positive outcomes we all desire, or the mortality statistics we all lament. It makes us feel good to clamor for more, and ever more nurses whenever – however possible. It is an easy call for an outsider to make. But the hard realities of mandating specific nurse ratios make the benefits ambiguous at best. Is one more hour of nurse surveillance worth the cost of those nurses' salary, over the course of the entire year, which could amount to over a million dollars? Money that could be spent on the physical upkeep of the hospital, or on new surgical equipment, or to assist in the laboratory, or to hire ancillary personnel? Hard limitations like this will limit the flexibility that a hospital manager, or any manager will need in order to operate their establishment with maximum efficiency at minimum cost. Still, the argument cam be made that if the new measures result in lives being saved, no other objection in terms of efficiency is relevant; after all – what is the point if not saving lives? That would be true if it were an absolute certainty what ratio really does protect patient health. More nurses is good; but costly. And at present, there does not appear to be a clear answer in terms of precisely what ratio is actually correct for all hospitals, in all instances. If we knew what the magic number was, then it would be arguably irresponsible to resist such a measure; but the literature is rife with uncertainty and debate regarding the nuts-and-bolts of staffing necessities to optimize patient outcomes. What is needed now isn't sweeping mandates that will impose a management straight-jacket on medical centers, but additional, targeted research to identify just what that ratio really is, and then the most accessible staffing solutions to meet it. Jumping the gun too soon will create a messy administrative tangle that will be costly and inconvenient to reverse if later studies clearly demonstrate the optimum ratio that we should have aimed for all along. REFERENCES Aiken, Linda H. PhD, Clarke, Sean P. PhD, RN. Sloane, Douglas M. PhD. Sochalski, Julie PhD, RN. Silber, Jeffrey H. MD, PhD. 2002. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. The Journal of the American Medical Association. 2002;288(16):1987-1993. doi: 10.1001/jama.288.16.1987 Aiken, Linda H. Sloane. Douglas M. Cimiotti. Jeannie P. Clarke, Sean P. Flynn, Linda. Seago, Jean Ann. Spetz, Joanne. Smith, Herbert L. 2010.Implications of the California Nurse Staffing Mandate for Other States. Health Services Research Volume 45, Issue 4, pages 904–921, August 2010 American Organization of Nurse Executives (2003). Policy Statement on Mandated Staffing Ratios. [Electronic version]. Available: www.monurseexec.org/documents/staffing_ratios03.pdf Clark, Cheryl. 2010. Does Mandating Nurse-Patient Ratios Improve Care? Cheryl Clark, for HealthLeaders Media, January 25, 2010. © 2011 HealthLeaders Media. http://www.healthleadersmedia.com/content/NRS-245408/Does-Mandating-NursePatient- Ratios-Improve-Care. Accessed 10/25/2011. Kane, R. L., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). Nursing Staffing and Quality of Patient Care. Evidence Report/Technology Assessment No. 151 Silber JH, Kennedy SK, Even-Shoshan O, et al. 2002. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96:1044-1052 Mark, B., D. W. Harless, and J. Spetz. 2009. “California's Minimum-Nurse-Staffing Legislation and Nurses' Wages” [accessed on October 29, 2011]. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w326. Health Affairs – Web Exclusive 28(2):326–34. Maslach C, Jackson SE. 1982. Burnout in health professions: a social psychological analysis. In: Sanders GS, 1982. Suls J, eds. Social Psychology of Health and Illness. Hillsdale, NJ: Lawrence Erlbaum Associates; 1982:227-251. Needleman, J., Buerhaus, P. I., Stewart, M., Zelevinsky, K., & Mattke, S. (2006). Nurse staffing in hospitals: is there a business case for quality? Health Affairs, 25, 204-211. Welton, J. M., Zone-Smith, L., & Fischer, M. H. 2006. Adjustment of inpatient care reimbursement for nursing intensity. Policy, Politics, & Nursing Practice, 7, 270-280 Welton, J. M., Unruh, L., & Halloran, E. J. (2006). Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. Journal of Nursing Administration, 36, 416-425. Van den Heede, K., E. Lasaffre, L. Diya, A. Vleugels, S. P. Clarke, L. H. Aiken, and W. Sermeus. 2009. “The Relationship between Inpatient Cardiac Surgery Mortality and Nurse Numbers and Educational Level: Analysis of Administrative Data. International Journal of Nursing Studies 46 (6): 796–803. Read More