Background
Identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced RN staffing land lower rates of adverse patient outcomes.
42 Code of Federal Regulations (42CFR 482.23(b) requires hospitals certified to participate in Medicare to "have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed". With such nebulous language and the continued failure of Congress to enact a quality nursing care staffing act to date, it is left to the states to ensure that staffing is appropriate to meet patients' needs safely.
Massive reductions in nursing budgets have resulted in fewer nurses working longer hours, while caring for sicker patients.
In a survey of almost 220,000 RNs from 13,000 nursing units in over 550 hospitals and a response rate of 70%, nurses reported to ANA that: 54% of nurses in adult medical units and emergency rooms do not have sufficient time with patients; overtime has increased during the past year with 43% of all RNs working extra hours because the unit is short staffed or busy; and that inadequate staffing affected unit admissions, transfers and discharges more than 20% of the time.
The benefits of increased RN staffing have been demonstrated. Each additional patient care RN employed (at 7.8 hours per patient day) will generate over $60,000 annually in reduced medical costs and improved national productivity. 1 This is only a partial estimate of the economic value of nursing omitting intangible benefits of reduced pain and suffering of patients and family members; the risk of patient re-hospitalization; benefits to the hospital such as improved reputation, reduced malpractice claims and payouts, and reduced compliance-related costs; and improved work environment that results in reduced turnover and risk of injury.
More recently, The "Nurse Staffing Strategy," (released March 2013) at the American Organization of Nurse Executives conference, found nurse fatigue also can negatively affect operational costs, as well as patient and employee satisfaction. Among the findings:
- 39 percent of respondents found current staffing levels inadequate, while 38 percent found them unsatisfactory
- 57 percent said workloads were not distributed evenly in the previous year, with 54 percent saying they had an excessive workload
- 77 percent said their organization had 12-hour nursing shifts
- 96 percent reported feeling tired at the beginning of their shift, and 92 percent while driving home after work
- 63 percent said vacancies affected scheduling and overtime staffing "more often than anticipated"
- 56 percent said their hospitals disregard required rest periods, and 65 percent said their hospitals do not have policies regarding cumulative days of extended shifts
Separate research recently published in JAMA Pediatrics found that nurse understaffing in neonatal intensive care units (NICU) leads to higher infection rates among very low-birth-weight babies.
Nurses therefore, have requested the assistance of elected officials on the state and federal level to protect patients by holding hospitals accountable for the provision of appropriate nurse staffing through legislative or regulatory means.
Three general approaches to assure sufficient nurse staffing have been utilized at the state level.
- The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff.
- The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation.
- A third approach is that of requiring facilities to disclose staffing levels to the public and /or a regulatory body.
The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. This approach aides in establishing staffing levels that are flexible and account for changes; including intensity of patient's needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources (ancillary staff, technology etc.). Establishing minimum upwardly adjustable staffing levels is statute may also aide the committee in achieving safe and appropiate staffing plans.
ANA's Principles for Nurse Staffing* provide recommendations on appropriate staffing and require nurses to be an integral part of the nurse staffing plan development and decision-making process. Unlike legislated mandated fixed ratios, this approach is not a "one size fits all". Instead hospitals have the flexibility of tailoring nurse staffing to the specific needs of patients based on factors including how sick the patient is, the experience and training of the nursing staff, technology, and support services available to the nurses.
States with Staffing Laws
- 15 states, plus the District of Columbia* enacted legislation and/or adopted regulations to address nurse staffing: CA, CT, IL, ME*, MN, NV, NJ, NY, NC, OH, OR, RI, TX, VT, and WA.
- 7 of these states require hospitals to have staffing committees responsible for plans and staffing policy – CT, IL, NV, OH, OR, TX, WA.
- CA is the only state stipulates that in law and regulations a required minimum nurse to patient ratios to be maintained at all times by unit.
- 5 states require some form of disclosure and / or public reporting – IL, NJ, NY, RI, VT
Other Approaches
- NC (2009) requested a study in the use of mandatory overtime as a staffing tool. No subsequent action taken.
- * DC and ME - legislation changed from original intent removing a staffing mandate.
*Utilization Guide for the ANA Principles for Nurse Staffing (2005) may be ordered at Nursesbooks.org
(1) Dall, Yaozhu, Seifert, Maddox & Hogan. (2009) "The Economic Value of Nursing" Medical Care: Vol 47:1.
Last updated 3/2013