(Editor’s note: The author of this post sent it to us to publish on the condition that we leave off her name. We don’t agree to do this very often, either on this blog or in letters published in AJN, but the topic addressed here is an important one.)
by matsuyuki/via Flickr
Nurse-to-patient ratios have been a hot topic at my hospital lately, as budget concerns are being blamed for increased nurse workloads. Cost-cutting measures have led to decreased ancillary staff; nurses are out on leave due to injuries sustained while moving patients without assistance; and the hospital administration’s staunch refusal to use contract or agency nurses has resulted in short-staffed intensive care units.
Although patient acuity and nurse skill level are considered in making shift assignments, certain situations can’t be predicted or planned for. An extra workload will always negatively affect the nurse and the patient. In the best of circumstances, the nurse won’t get lunch or breaks and the nonessential elements of patient care, such as baths and linen changes, will be skipped. The busier the assignment, the more likely that something critical will be missed. (For more on this, see the Muse, RN’s blog post, Nurse-Staffing Ratios: Nurse’s Perspective.)
A coworker of mine made a medication error a few weeks ago. It was a multifactorial error—the medication had been ordered wrong, labeled wrong, and administered wrong—and was investigated accordingly.
That particular nurse was also “tripled,” with two ICU trauma patients and one critically ill medical resident patient. The nurse’s workload wasn’t factored into the documentation or investigation of the error, though, since the nurse manager didn’t consider it relevant.
I heard her say, “An extra patient shouldn’t make any difference in the standard procedure for passing medications.”
Not an ideal world. While that statement is, ideally, true, it’s also a pretty clear indicator of how removed administrators can be from the realities of bedside care. When the workload overwhelms the capabilities of the staff, errors are likely. According to a report by Linda Aiken and colleagues called Implications of the California Nurse Staffing Mandate for Other States, not only do nurses report better patient outcomes with lower nurse-to-patient ratios, but with appropriate staffing, mortality rates are predicted to decrease 10.6%–13.9%.
With such strong statistical support of lower nurse-to-patient ratios, a budget-based decision to understaff hospital units looks like an actuarial gamble based on an unethical risk–benefit analysis. With lives at stake, it’s an obvious losing bet from the start.
Inadequate staffing and poor nurse to patient ratio are some of the rising national and global healthcare issues. I recently read upon an article regarding California’s mandated nurse staffing implementation and research, and I too agree that there’s no positive outcomes in having a shortage of nurses in providing utmost care for the best patient outcomes. How much this affects patient safety, care, and mortality rates are terrifying. In my past experience working on a med-surg floor as a patient care tech, the insane overworked schedule of nurses and other healthcare workers caused not only poor outcomes in the patients but also increase in nurse turnovers. Perhaps, there’s more than the “administrator’s” scheduling problem that causes such issue and this should be further investigated in order to enhance our healthcare system for our patients and nurses.
AJN this is very important but I would request that all refrain from the typical “it’s the administrtation that does not understand” rhetoric. We know very little of this situation other then the nurse had three patients and the manager believes the practice of passing meds is not dependent on staffing. I would also point out that evidence requires more then one source. Let’s all keep working to find a better way without pointing fingers.
With statistics like the ones presented in this essay it should change the way management views staff to patient ratios (even as mentioned above, this is already well documented). Even if you took the lower percentage of the “10.6%–13.9%.” mortality ratio, that’s still one life out of ten! The ethics of this topic are intense. Budget or life. What is the price of a person’s life?
What’s so unfortunate about this is that not only are nurses obviously suffering, but also others. Imagine the med errors that are not caught that can leas to harm or other event that cause harm or een death. All of this bc th pt ratio isn’t relevant. Nurse managers should be requires to work as a staff nurse on a regular basis. They need not forget what it is like and then they would see what is more important in their budgets and in the grand sceme of things.
This is not a blame game. Lives are at stake here it doesn’t matter why it just matters that it is and we have to fix it!
AJN – Thank you for posting this poignant and timely post! I have been reading this excellent nurse blogger’s work for some time and he/she always makes important points, using the expert first-hand knowledge of a working nurse. Thank you again for maintaining this blog and for posting this and other impressive nurse bloggers’ work.
Terri, we appreciate the supportive comment very much. (But don’t assume you know who this blogger is, unless you have inside information, as you very well might!) -Jacob, blog editor
The points made by this author have been well documented. Hospital Acquired Infections, particularly BSI’s have been affected by staffing ratios as well. Robbing Peter to pay Paul is NEVER in the best interest of the patient.