(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.)
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.