By Debra Wood, RN, contributor
March 18, 2010 - Nurses have known intuitively for years that when unit staffing allows them to spend more time with patients, outcomes improve and patients receive safer care. Researchers and nursing experts have spent considerable effort trying to determine the best staffing and why nurses at the bedside save lives.
Allison Squires, RN, Ph.D., said that a 5:1 patient-to-nurse ratio is a good starting point for safe staffing.
“There is more and more evidence every year that comes out and shows there is a magic number in a med-surg setting that the right number of nurses makes for better patient outcomes and enhances patient safety, simply because you have the time to pay attention to all of the details you have to to keep the patient safe,” said Allison Squires, Ph.D., RN, assistant professor at the New York University College of Nursing.
Squires said that five patients per nurse tends to pop up as the optimal level of staffing. But she said that nursing demographics—including skill and experience levels—affect staffing needs. Nurses must have the time to address problems and assess whether interventions, such as medications or treatments, have relieved symptoms.
Isis Montalvo, RN, MBA, MS, said that safe staffing is not just about the number of patients per nurse but also the type of nurse, the number of nurses present, their education and certification.
“Nurses make a difference in patient outcomes,” agreed Isis Montalvo, MBA, MS, RN, director of the National Center for Nursing Quality at the American Nurses Association. However, she added, “The type of nurse, the number of nurses present, their education and certification can have an effect.”
The number of nurses needed varies depending on patient acuity and nurse experience and competencies, so it’s difficult to prescribe a ratio, Montalvo said. Yet something as simple as assessing a patients’ risk of falling and identifying and implementing steps to prevent a fall and assessing skin integrity and risk of breakdown, for example, are nursing responsibilities that contribute to patient safety.
In 2002, Linda H. Aiken, Ph.D., FAAN, FRCN, RN, the Claire M. Fagin leadership professor of nursing at the University of Pennsylvania School of Nursing in Philadelphia, published results of her research in the Journal of the American Medical Association, indicating each additional surgical patient per nurse was associated with a 7 percent increase in the likelihood of dying within 30 days of admission and a 7 percent increase in the odds of failure-to-rescue. While Aikens and colleagues did not directly indicate the number of nurses needed to properly care for surgical patients, the researchers determined that the difference from 4 to 6 and from 4 to 8 patients per nurse would be accompanied by 14 percent and 31 percent increases in mortality, respectively.
Lillee Smith Gélinas, RN, MSN, cited the business model for better nurse staffing—it saves money by decreasing complications and shortening length of stay.
Starting in June 2010, the Centers for Medicare & Medicaid Services will require hospitals to report their failure-to-rescue rates, a nurse-sensitive care measure, said Lillee Smith Gélinas, RN, MSN, vice president and chief nursing officer of VHA, Inc.
“Failure-to-rescue rates truly are an indication of time at the bedside, and an indication of a hospital’s awareness of the correlation between nurse staffing and outcomes,” said Gélinas, adding, “Some hospitals will be in a world of hurt.”
To ensure nothing bad happens, she explains, nurses must spend time with patients observing, monitoring and assessing for subtle changes. Nurses waste too much time searching for equipment and supplies, Gélinas added. VHA’s Return to Care program focuses on helping nurses spend more time on direct patient care.
A 2008 time and motion study by Ascension Health and Kaiser Permanente, funded by the Robert Wood Johnson Foundation and the Gordon and Betty Foundation, investigated how nurses spent their time on 35 medical-surgical units. They found that patient care activities accounted for only 19.3 percent of nurses’ time, with documentation consuming 35.3 percent, medication administration 17.2 percent and care coordination 19.3 percent of the day.
Sue Hassmiller, RN, FAAN, Ph.D., indicated that safety also requires improved communication and working together as medical teams.
Many changes to care delivery that have been pioneered by Transforming Care at the Bedside (TCAB), such as patient safety rounds at Kaiser Permanente Roseville, aim to increase nurses’ time with patients. TCAB is nurse driven and helps engage nurses in their job, said Susan Hassmiller, Ph.D., RN, FAAN, the Robert Wood Johnson Foundation senior adviser for nursing.
“When you get rid of paperwork and cut down on hunting and gathering that goes on in units and get back to patient care, nurses are at the bedside and are more observant,” Hassmiller said. “You are more likely to catch something. When nurses are not at the bedside, bad things happen.”
Many small innovations added together can add time back to nurses’ time with patients, she said.
“It’s not just about numbers of nurses or ratios; it’s about having nurses with the competencies to meet the needs of the patients,” said Linda Bell, RN, MSN, a clinical practice specialist at the American Association of Critical-Care Nurses. “A body is better than nobody, but not a lot.”
Nurses must be knowledgeable about the patient needs and what might go wrong, and the skills to deal with it. When that occurs, Bell said, patients should be safer. The ideal is to align the experience, skills and competencies with the patient population.
A recent study from the University of Michigan, Ann Arbor, reported in March 2010 in the journal Medical Care, found that absolute risk of mortality decreased with improved nurse staffing levels. For each additional full-time equivalent nurse per patient day, risk of dying decreased by 0.25 percent.
Despite all of the evidence, hospitals facing increasingly challenging budgets may reduce nursing staff. Gélinas maintains they cannot afford to, because research shows that higher levels of nursing time at the bedside result in fewer adverse events and shorter length of stay.
“Our problem is we are making knee-jerk reaction budget cuts that take nurses away from the bedside,” Gelinas said. “We are actually increasing length of stay and adverse outcomes, which increases the cost: the opposite effect of the intervention.”
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