Nurse Staffing Makes a Difference

A few weeks ago I talked about the “National Quality Strategy Initiative” started by the Obama administration; a public-private partnership to improve the quality of patient care and make hospitalizations safer by reducing medical errors as a part of the Affordable Care Act.  This initiative consists of decreasing preventable hospital-acquired conditions by 40-percent by the end of 2013 compared to rates of 2010. The goal being 60,000 lives saved due to medical errors.  A second part of the National Quality Initiative is to improve patient healing without complication.  The goal that, within the same time period, hospital readmissions will drop 20 percent within 30 days of discharge.

Within the last few months a studies have been released discussing the impact of nurse staffing on patient outcomes and hospital readmission rates.  This is not a new topic, but hospitals are facing drastic changes to funding and reimbursement for care provided during a hospitalization within the next few years.  1300 hospitals have signed on to this initiative as part of this Affordable Care Act.  I believe this initiative and the research that has been brought forth has the potential to be a vehicle for major changes in the way hospitals think about nurse staffing levels

A study, funded by the Robert Wood Johnson Foundation, published in the April 2011  journal Health Services Research discussed the correlation between RN staffing and overtime hours and patient ER visits and hospital readmissions. A very positive correlation was found between them. As nurse staffing dropped and overtime hours increased so did visits to the ER and readmissions to the hospital.  There was also a direct correlation found between RN staffing and patient satisfaction with and preparedness for discharge.  An article in the Milwaukee Courier Online quoted the research article’s findings to be:

“We know that patients who aren’t properly prepared to be discharged are more likely to be readmitted to the hospital and we also know that if nurses have more hours allocated to work with patients, they have more time to perform critical functions that require R.N.- level expertise, like discharge teaching,” said Weiss. “This study shows us that investing in nursing care hours could potentially be offset by the savings that could be realized in reductions in readmission and emergency department use.”

I think it is vital for hospitals to takeaway from this research what has the biggest impact on patient success throughout their hospitalizations, as well as at discharge, as they sign on to the initiative. Make quality nursing care your #1 priority.

I will very openly admit (which I’m sure is not surprising) that I am a huge supporter of increased nursing staffing in an effort to improve patient outcomes.  Most hospitals (mine included) have staffing matrixes on all of their nursing units. Staffing matrixes define that, for example, if a unit has 20 ICU patients, so you should have 11 nurses.  Staffing matrixes have positives and negatives. Within a hospital, matrixes keep staffing very fair between units. Between ICU’s within the same hospital, the nurse to patient ratio is the same.  The negative about a staffing matrix is that it doesn’t allow for changes in unit acuity.  So for the unit that has 20 stable, standard ICU patients; 11 nurses is fine. Everyone has time to take care of their patients appropriately and help each other.  However when a shift comes up, as it does in the ebbs and flows of health care, when 8 of those 20 patients need to be singled because of how unstable they are or the equipment they’re on, as a unit you are immediately short-staffed and looking for nurses to work overtime and come in extra or forced to pair patients that really are too busy for 1 nurse to manage and provide quality care for.

I have always felt very passionately that nurse staffing ratios should be dictated by patient care needs.  This is something that is not done, as far I know, at any hospital in the country.  Patients who are unable to care for themselves need as close to 1 on 1 attention as they can get.  In regards to caring for themselves, I define it as they are not able to toilet themselves, turn themselves, or alert the nurse when they are in need; whether they are quadriplegic, comatose, or sedated on the ventilator.   These medical conditions and states of health are a few examples of patient conditions that face high rates of hospital acquired infections and injuries.

I believe, for example, a patient that is a new quadriplegic would, in the ICU be singled- ensuring frequent oral care, skin care, turning, and ROM to prevent any hospital acquired complications (infections and pressure ulcers) and as the individual transitioned to acute care the nurse caring for them would have at most 1 or two other patients.  Ensuring that they are able within their shift to have time to provide frequent, necessary nursing care.  Patients that are able to walk, take themselves to the bathroom and so on, would be able to successfully be cared for by a nurse on an acute care floor that  had 5 or 6 other patients.  It would be a really big shift in prioritization of patient care to staff a nursing unit based on the acuity of individual patients versus the sum total of the whole unit and giving each nurse the same number of patients.

This would, up front, increase costs for a hospital.  The expectation would be, that in the long run,  patient care and outcomes would be at their best.  By allowing nurses to focus completely on a single complex patient we work to build and enhance the patient nurse relationship and encourage nurses to be an active driving member of the care team.

A study in the New England Journal of Medicine in March 2011, titled Nurse Staffing and Inpatient Hospital Mortality researched this topic and I quote the very exciting conclusion below:

In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.

The important part of this research is the recognition for the importance of nursing care and how vital it is in impacting patient outcomes.  As hospitals are cutting ancillary staff- unit clerks and nursing assistant positions; as they tighten and push staffing matrixes in an era of budget constraints; as nursing burnout and turnover within the hospital settings continues to rise; and as nursing responsibility climbs everyday so does the expectation that nurses will do more with less.

This is just the beginning of a very deep and important discussion.  The changes our economy and health care system face in the future will affect all of us as patients and health care workers. Stay tuned!

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